Christopher Collinson
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-060 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2021-0361 |
| Registered primary source | SRC-060 |
| Report date | 2021-10-26 |
| Coroner area | Birmingham and Solihull |
| Clinical setting | Acute medical unit/hospital |
| Care transition | Arrival and allocation to medical assessment |
| Primary workflow group | Triage, observations and decision support |
| 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: Allocation status and prescribing choices were created and acted on within the acute medical unit; both failures occurred in local receiving workflows.
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-083 |
| Non-exclusive mechanism codes | VIS, LOOP, HF, ALERT, GOV |
Qualification recorded in the dataset: Natural-causes conclusion; report did not state that either digital issue caused or contributed to death. Response says PICS replaced the hybrid process and rejected a generic confirmation alert because of alert-fatigue 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
The coroner found no way for other clinicians to know that an allocated patient remained unseen and considered wrong medication selection too easy under pressure
Requested action
University Hospitals Birmingham NHS Foundation Trust to address delayed-assessment visibility and safer electronic prescribing selection
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Hybrid paper record, electronic allocation system and JAC EPMA |
| Digital function | Patient allocation/status and electronic prescribing |
| Failure mode | Electronic allocation showed a doctor as responsible although the patient had not been assessed; a confusing prescribing dropdown supported selection of prophylactic rather than intended therapeutic enoxaparin |
| Human-factors issue | High workload, distraction, ambiguous allocation state and similar prescribing options increased slip risk |
| Workflow issue | The doctor did not release the allocation; no automatic ageing or escalation exposed that assessment remained outstanding; prescribing accepted the unintended option |
| Information issue | The electronic state was interpreted as completed assessment, while the selected dose did not match clinical intent |
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.