Steven Welch
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-122 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2018-0267 |
| Registered primary source | SRC-122 |
| Report date | 2018-08-07 |
| Coroner area | South Wales Central |
| Clinical setting | Acute and emergency care |
| Care transition | Welsh hospital to English specialist service |
| Primary workflow group | Diagnostic results and investigations |
| Primary browsing context | Acute and emergency care |
| Predominant information boundary | Between care settings |
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 | Laboratory, radiology or diagnostic service, Tertiary or specialist care |
| Information or work-item origin | Laboratory, radiology or diagnostic service |
| Origin care context(s) | Diagnostic service |
| Expected action destination | Tertiary or specialist care |
| Destination care context(s) | Tertiary or specialist care |
| Directional pathway | Laboratory, radiology or diagnostic service → Tertiary or specialist care |
| Care-setting span | Multiple care settings |
| Sector boundary | Health services only |
| Failure point | Transfer or interface |
| Classification confidence | high |
Classification note: Urgent radiology images and the report arose in a Welsh hospital diagnostic service and were required by an English specialist service; incompatible systems forced print-and-fax transfer without reliable delivery.
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, RES, LOOP, GOV |
Qualification recorded in the dataset: The coroner expressly stated that the identified errors were unlikely to have caused the death but could create future risk
“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
Incompatible systems and manual transfer created delay in urgent cross-border care
Requested action
Welsh Ambulance Services NHS Trust, Welsh health boards and NHS Wales bodies to act
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Cross-border radiology systems, print and fax |
| Digital function | Radiology-image and report transfer |
| Failure mode | There was no software route for direct Wales-to-England image transfer, so staff relied on printing and faxing with delay and uncertainty |
| Human-factors issue | Users had to understand and manually bridge incompatible cross-border pathways |
| Workflow issue | The transfer process lacked resilient electronic delivery, acknowledgement and escalation |
| Information issue | The receiving service did not receive a timely complete diagnostic package |
Downstream Defence trace
Canonical candidate requirements that cite this report: REQ-006, REQ-012. 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.