Deceased name redacted
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-127 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2018-0405 |
| Registered primary source | SRC-127 |
| Report date | 2018-12-21 |
| Coroner area | Shropshire, Telford and Wrekin |
| Clinical setting | Community mental-health care |
| Care transition | Risk assessment and longitudinal progress review |
| Primary workflow group | Record integrity and provenance |
| Primary browsing context | Mental health 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 | Community mental-health care |
| Information or work-item origin | Community mental-health care |
| Origin care context(s) | Community care |
| Expected action destination | Community mental-health care |
| Destination care context(s) | Community care |
| Directional pathway | Community mental-health care → Community mental-health care |
| Care-setting span | One care setting |
| Sector boundary | Health services only |
| Failure point | Originating service |
| Classification confidence | high |
Classification note: Risk assessments and progress notes were created and used within community mental-health care; update or validation behaviour could obscure original content and amendment state at record creation.
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, GOV |
Qualification recorded in the dataset: The coroner expressly said the two reported issues could not be said to have caused or contributed to this death but could do so in others; the page was published or migrated in 2024
“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
Electronic record provenance and interpretability required improvement
Requested action
Midlands Partnership NHS Foundation Trust to act
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Electronic mental-health record |
| Digital function | Amendment provenance and risk-record interpretation |
| Failure mode | Entries described as updated or validated could overwrite or obscure original content, and the relationship between risk assessments and progress notes was unclear |
| Human-factors issue | Users and later reviewers could not readily determine what had originally been written or how the record views should be interpreted together |
| Workflow issue | No clear rule defined when risk assessments were updated, how they related to progress notes or what summary function they served |
| Information issue | Original content, amendment state and the role of each record view were insufficiently visible |
Downstream Defence trace
Canonical candidate requirements that cite this report: REQ-008. 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.