Brian Bicat
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-124 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2018-0277 |
| Registered primary source | SRC-124 |
| Report date | 2018-05-29 |
| Coroner area | West Yorkshire (West) |
| Clinical setting | Primary and community care |
| Care transition | National fire-risk guidance to local prescribing |
| Primary workflow group | Medication and prescribing |
| Primary browsing context | Primary and community care |
| Predominant information boundary | National-to-local information flow |
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 | National programme or service, Primary care |
| Information or work-item origin | National programme or service |
| Origin care context(s) | National programme or service |
| Expected action destination | Primary care |
| Destination care context(s) | Primary care |
| Directional pathway | National programme or service → Primary care |
| Care-setting span | One care setting |
| Sector boundary | Health services only |
| Failure point | Transfer or interface |
| Classification confidence | high |
Classification note: National paraffin-emollient fire-risk knowledge was expected to appear consistently in locally configured primary-care prescribing systems; deployment and maintenance across CCG configurations were inconsistent.
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, INT, GOV |
Qualification recorded in the dataset: The accidental death followed burns intensified by paraffin-based emollients; inconsistent digital warnings were one element of a much wider labelling, advice and data concern and were not isolated causally
“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
Inconsistent prescribing alerts and warnings formed part of a wider concern about communicating paraffin-emollient fire risk
Requested action
National bodies, manufacturers, NHS England and local organisations to act
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | SystmOne and OptimiseRx |
| Digital function | Paraffin-emollient fire-risk warnings |
| Failure mode | Prescribing systems appeared to be updated by individual CCGs, producing inconsistent alerts and warnings about paraffin-emollient fire risk |
| Human-factors issue | Clinicians could not rely on a consistent warning model for the same product risk across local configurations |
| Workflow issue | Governance did not ensure that material safety advice was deployed and maintained consistently |
| Information issue | Fire-risk knowledge for paraffin-based emollients was represented differently depending on system and locality |
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.