Michael Drewell
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-121 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2018-0259 |
| Registered primary source | SRC-121 |
| Report date | 2018-08-30 |
| Coroner area | West Yorkshire (Eastern) |
| Clinical setting | Acute hospital care |
| Care transition | Procedure plan to ward prescribing |
| Primary workflow group | Medication and prescribing |
| Primary browsing context | Acute and emergency care |
| Predominant information boundary | Hybrid paper and digital record |
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 | Secondary acute or outpatient care |
| Information or work-item origin | Secondary acute or outpatient care |
| Origin care context(s) | Secondary care |
| Expected action destination | Secondary acute or outpatient care |
| Destination care context(s) | Secondary care |
| Directional pathway | Secondary acute or outpatient care → Secondary acute or outpatient care |
| Care-setting span | One care setting |
| Sector boundary | Health services only |
| Failure point | Transfer or interface |
| Classification confidence | high |
Classification note: The anticoagulation-duration instruction arose in a handwritten procedure note and was expected in the ward's electronic prescribing workflow within the same hospital; it was lost between record representations.
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 | PROV, VIS, HF, LOOP |
Qualification recorded in the dataset: The coroner said it was not possible to determine whether the missed duration caused the death; inclusion preserves that uncertainty
“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
The hybrid record allowed an important medication-duration instruction to be missed
Requested action
Leeds Teaching Hospitals NHS Trust to act
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Handwritten clinical note and electronic medication record |
| Digital function | Anticoagulation-duration communication |
| Failure mode | The intended six-week anticoagulation duration was recorded in handwriting but not carried into the electronic record used by the junior doctor |
| Human-factors issue | The workflow expected clinicians to infer that a separate paper note contained a time-limited instruction |
| Workflow issue | No reconciliation or review task transferred the stop date into the prescribing workflow |
| Information issue | The duration instruction was split across paper and electronic representations |
Downstream Defence trace
Canonical candidate requirements that cite this report: REQ-007. These links are analytical translations and do not make the requirement a coronial recommendation or a validated Defence control.
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.