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Jacob Sulaiman

Evidence boundary. This page is a structured project extraction from the linked primary Prevention of Future Deaths source. It is not the report text. Do not infer cause, prevalence or product-wide performance beyond the source and the explicit qualification below.

Open the primary Judiciary source · Source register: SRC-120 · Return to all included reports · Open the case–mechanism/evidence map

Report metadata

Field Value
PFD reference 2018-0252
Registered primary source SRC-120
Report date 2018-07-06
Coroner area London (Inner) North
Clinical setting Retirement housing and emergency response
Care transition Telecare, local response officers and ambulance service
Primary workflow group Risk, care planning and safeguarding
Primary browsing context Cross-setting and multi-agency care
Predominant information boundary Across health and non-health sectors

The workflow, browsing-context and predominant-boundary fields are retained navigation aids. They are not additional coronial findings, and a single primary value cannot express every aspect of a multi-setting or multi-mechanism report.

Care-pathway classification

This classification distinguishes where safety-relevant information or work arose, where action was expected and where the digital or information workflow failed. It is a project coding of the source, not a coronial statement. “Origin” does not mean the organisation caused the harm.

Dimension Project classification
Settings and pathway participants Social care, care home or supported living, Ambulance, NHS 111 or urgent response
Information or work-item origin Multiple settings or services
Origin care context(s) Social care, Ambulance or urgent response
Expected action destination Multiple settings or services
Destination care context(s) Social care, Ambulance or urgent response
Directional pathway Multiple settings or services → Multiple settings or services
Care-setting span Multiple care settings
Sector boundary Health and social care
Failure point Transfer or interface
Classification confidence high

Classification note: Careline contacts, local response visits and ambulance attendance formed a shared emergency history. Later social-care and ambulance responders lacked a reconciled view, making cross-sector information transfer the predominant failure.

Classification confidence applies only to this care-pathway coding. It is separate from extraction confidence, source authority and causal certainty.

Evidence status and qualification

Field Status
Extraction confidence high
Verification status Primary source linked; high-confidence extraction
Response evidence status Not assessed in this dataset
Registered response sources None registered for this row
Non-exclusive mechanism codes INT, VIS, LOOP, GOV

Qualification recorded in the dataset: The death was accidental; the report states that fuller information may have affected capacity assessment and management, not that the database failure caused the death

“Response evidence noted” means only that the row qualification refers to response/respondent evidence or records a recipient's post-report position. The linked IDs enumerate the official response attachments registered for this row; they do not imply that every response supports every part of the qualification, and they do not establish implementation. “Not assessed” makes no claim about whether a response exists.

Structured project extraction

These fields are analytical summaries, not quotations.

Project summary of the coroner's concern

Incomplete shared information deprived emergency responders of a holistic picture

Requested action

London Borough of Camden to act

Digital safety characterisation

Dimension Project extraction
System or record type Careline and Wellbeing shared database
Digital function Telecare contact-history sharing
Failure mode Response officers saw only information placed on the shared database and could not readily retrieve the nature, number and outcomes of recent calls and visits
Human-factors issue Responders had to assess an emergency from an incomplete contact history
Workflow issue No workflow reconciled contacts, visit outcomes and ambulance attendance across the services
Information issue Recent calls and the outcome of prior responses were not readily visible to later responders

Downstream Defence trace

No canonical candidate Defence requirement currently cites this report. This does not imply that the mechanism is irrelevant; any mapping must be added and qualified in the controlled requirements register.

The included-case dataset preserves early legacy_military_relevance and legacy_derived_requirement fields for audit history. They are not published here as requirements and must not override the canonical REQ register. New report rows do not need to populate them.