Cuthbert Hingert
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-123 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2018-0280 |
| Registered primary source | SRC-123 |
| Report date | 2018-08-01 |
| Coroner area | Isle of Wight |
| Clinical setting | Acute hospital care |
| Care transition | Admission and medication reconciliation |
| Primary workflow group | Medication and prescribing |
| Primary browsing context | Acute and emergency care |
| Predominant information boundary | Within a care setting |
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 | Receiving or action service |
| Classification confidence | high |
Classification note: Medication information was available in the hospital JAC database but the admitting and prescribing team did not check or use it at the clinical decision point.
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, VIS, HF, GOV |
Qualification recorded in the dataset: The report identifies a medication-database and training failure among wider clinical circumstances; the page displays 2018-0280 while the attachment filename displays 2018-0279
“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
Failure to use the medicines database and inadequate training created a serious prescribing risk
Requested action
Isle of Wight NHS Trust to act
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | JAC medicines database |
| Digital function | Medication reconciliation and interaction checking |
| Failure mode | The JAC medicines database was not checked, allowing concurrent anticoagulant and antiplatelet treatment to proceed without the intended safeguard |
| Human-factors issue | Staff had not received sufficient training to understand and use the database reliably |
| Workflow issue | Medication reconciliation did not require a completed database check and accountable review |
| Information issue | Relevant medication information and risk were available but not surfaced in the active decision |
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.