Alexander Braund
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-003 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2022-0407 |
| Registered primary source | SRC-003 |
| Report date | 2022-12-20 |
| Coroner area | Nottingham and Nottinghamshire |
| Clinical setting | Secure healthcare |
| Care transition | Clinical record to investigation |
| Primary workflow group | Record integrity and provenance |
| Primary browsing context | Secure and custodial care |
| Predominant information boundary | Hybrid paper and digital record |
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 | Prison, custody or secure healthcare, Police, local authority or other non-health agency |
| Information or work-item origin | Prison, custody or secure healthcare |
| Origin care context(s) | Secure or custodial healthcare |
| Expected action destination | Police, local authority or other non-health agency |
| Destination care context(s) | Non-health agency |
| Directional pathway | Prison, custody or secure healthcare → Police, local authority or other non-health agency |
| Care-setting span | One care setting |
| Sector boundary | Health and non-health sectors |
| Failure point | Transfer or interface |
| Classification confidence | high |
Classification note: The source identifies an amendment in the prison-healthcare SystmOne record and explicitly compares the live audit information with the printed record used at the inquest. The retrospective amendment was not readily apparent in that printed representation, so the pathway is coded from secure healthcare to the non-health inquest/investigation view.
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-017 |
| Non-exclusive mechanism codes | PROV, VIS, GOV |
Qualification recorded in the dataset: One investigated record; prevalence unknown
“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
Record integrity and safety features required clarification
Requested action
TPP and care organisations to act
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | SystmOne |
| Digital function | Audit/provenance |
| Failure mode | Retrospective amendment was not apparent on printed summary |
| Human-factors issue | Ordinary view implied all text existed at original time |
| Workflow issue | Audit view and routine/printed representation diverged |
| Information issue | Amendment provenance hidden in used representation |
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.