Hugo Carlos
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-061 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2023-0038 |
| Registered primary source | SRC-061 |
| Report date | 2023-02-01 |
| Coroner area | Berkshire |
| Clinical setting | Primary care/radiology surveillance |
| Care transition | Private imaging to GP and longitudinal follow-up |
| Primary workflow group | Screening and longitudinal surveillance |
| Primary browsing context | Primary and community 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 | Primary care |
| Information or work-item origin | Primary care |
| Origin care context(s) | Primary care |
| Expected action destination | Primary care |
| Destination care context(s) | Primary care |
| Directional pathway | Primary care → Primary care |
| Care-setting span | One care setting |
| Sector boundary | Health services only |
| Failure point | Receiving or action service |
| Classification confidence | high |
Classification note: Private imaging supplied the antecedent surveillance recommendation, but the coded digital safety issue arose after it had reached the GP record: EMIS could store the future diary entry but did not surface it as an owned arbitrary follow-up task. Origin and destination are therefore coded to primary care; the private imaging is contextual antecedent.
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 | No official response located |
| Registered response sources | None registered for this row |
| Non-exclusive mechanism codes | LOOP, GOV, VIS, HF, ALERT, IDPOP |
Qualification recorded in the dataset: Follow-up occurred; the inquest did not identify the EMIS task gap as causal. No official response was located
“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 warned that patients could become lost to necessary follow-up because EMIS lacked the described scheduled-task capability
Requested action
EMIS to take action within its power to prevent patients being lost to future investigation and surveillance
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | EMIS primary-care EHR and diary-date function |
| Digital function | Future tasking, surveillance recall and alerting |
| Failure mode | A future diary entry was visible only after opening the patient record and could not generate a pop-up for an arbitrary surveillance task outside an EMIS-defined list |
| Human-factors issue | Clinicians received no proactive cue unless they independently reopened the record; safety depended on patient memory and initiative |
| Workflow issue | No owned future task, work queue, deadline escalation or closure state supported planned surveillance |
| Information issue | The follow-up requirement could be stored but was not operationally surfaced |
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.
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