Morris Reddington
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-004 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2021-0312 |
| Registered primary source | SRC-004 |
| Report date | 2021-05-21 |
| Coroner area | Nottingham and Nottinghamshire |
| Clinical setting | Ambulance/emergency care |
| Care transition | Ambulance to emergency department |
| Primary workflow group | Referral, handover and transfer |
| 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 | Ambulance, NHS 111 or urgent response, Secondary acute or outpatient care |
| Information or work-item origin | Ambulance, NHS 111 or urgent response |
| Origin care context(s) | Ambulance or urgent response |
| Expected action destination | Secondary acute or outpatient care |
| Destination care context(s) | Secondary care |
| Directional pathway | Ambulance, NHS 111 or urgent response → Secondary acute or outpatient care |
| Care-setting span | Multiple care settings |
| Sector boundary | Health services only |
| Failure point | Transfer or interface |
| Classification confidence | high |
Classification note: The ambulance ePRF did not transfer into the hospital record and required a separate, unfamiliar retrieval path, so ED staff routinely did not review it.
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 | Response evidence noted |
| Registered response sources | SRC-015, SRC-079 |
| Non-exclusive mechanism codes | LOOP, GOV, HF, INT, RES |
Qualification recorded in the dataset: Official joint response proposed FHIR delivery; respondent plan is distinct from coronial finding
“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
Failures in handover of patient information created future-death risk
Requested action
Ambulance, hospitals, commissioners and NHS England to act
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Ambulance ePRF portal and hospital EHR |
| Digital function | Handover/record access |
| Failure mode | Separate credentials, unfamiliar navigation and no automatic hospital-record link meant ePRFs were routinely not reviewed |
| Human-factors issue | Retrieval friction encouraged reliance on verbal handover |
| Workflow issue | Finalisation and review did not form a reliable transfer workflow |
| Information issue | Ambulance detail inaccessible in receiving record |
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.
Return to all included reports · Open the corpus profile · Review assurance and uncertainty · Open the case–mechanism/evidence map