Karl Willis
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-128 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2018-0256 |
| Registered primary source | SRC-128 |
| Report date | 2018-08-24 |
| Coroner area | Exeter and Greater Devon |
| Clinical setting | Primary care and online pharmacy |
| Care transition | GP medication control to online prescribing |
| Primary workflow group | Medication and prescribing |
| Primary browsing context | Primary and community care |
| Predominant information boundary | Patient-to-service channel |
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 | Primary care, Patient or home, Pharmacy or dispensing service |
| Information or work-item origin | Multiple settings or services |
| Origin care context(s) | Primary care, Patient or public |
| Expected action destination | Pharmacy or dispensing service |
| Destination care context(s) | Pharmacy |
| Directional pathway | Multiple settings or services → Pharmacy or dispensing service |
| Care-setting span | Multiple care settings |
| Sector boundary | Health services only |
| Failure point | Multiple points |
| Classification confidence | high |
Classification note: The GP medication stop and the patient's online self-certification were separate safety-relevant inputs to an online pharmacy prescribing decision. Optional GP notification and lack of verification affected both transfer and destination safeguards.
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 | ALERT, LOOP, INT, HF, GOV |
Qualification recorded in the dataset: Amitriptyline and morphine toxicity formed part of the medical cause of death and the online supply formed part of the circumstances; the report does not establish that interface design alone 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
Self-certification and optional GP notification removed safeguards against unsafe online access to amitriptyline
Requested action
NHS England to act
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Online pharmacy questionnaire and GP-notification choice |
| Digital function | Remote prescribing assessment and information sharing |
| Failure mode | The online route permitted unchecked self-certification and allowed the patient to prevent notification of the GP who had stopped amitriptyline |
| Human-factors issue | A vulnerable patient could deliberately provide inaccurate answers while the interface treated self-report and consent choice as sufficient safeguards |
| Workflow issue | No mandatory verification or closed-loop GP notification reconciled the online prescription with the active medication plan |
| Information issue | The online prescriber did not receive or contribute to a shared, authoritative medication-risk picture |
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.