Ania Sohail
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-064 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2023-0046 |
| Registered primary source | SRC-064 |
| Report date | 2023-02-07 |
| Coroner area | Manchester North |
| Clinical setting | Online pharmacy/mental-health inpatient/primary care |
| Care transition | Multiple online pharmacies to GP and inpatient mental-health team |
| Primary workflow group | Medication and prescribing |
| Primary browsing context | Cross-setting and multi-agency 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 | Pharmacy or dispensing service, Primary care, Inpatient or secure mental-health care |
| Information or work-item origin | Multiple settings or services |
| Origin care context(s) | Pharmacy, Primary care, Secondary care |
| Expected action destination | Multiple settings or services |
| Destination care context(s) | Pharmacy, Primary care, Secondary care |
| Directional pathway | Multiple settings or services → Multiple settings or services |
| Care-setting span | Multiple care settings |
| Sector boundary | Health services only |
| Failure point | Multiple points |
| Classification confidence | high |
Classification note: Distinct concerns involved online-pharmacy supply visibility, GP information and inpatient mental-health documentation; relevant origins, destinations and failure points were multiple.
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 | INT, ALERT, VIS, LOOP, PROV, HF, GOV |
Qualification recorded in the dataset: Jury identified ineffective searches, inadequate post-leave assessment and omitted safety plans as contributors; online-pharmacy fragmentation also appeared in the conclusion but independent causal weight was not quantified
“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 integrated system across online pharmacies and identified inaccessible GP information and deficient ward documentation
Requested action
Department of Health and Social Care and Greater Manchester Mental Health NHS Foundation Trust to address online prescribing/information-sharing risks and care-recording controls
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Separate online-pharmacy records, Summary Care Record and mental-health care-planning records |
| Digital function | Cross-provider prescribing visibility, record sharing, care planning and audit |
| Failure mode | Each pharmacy could check only its own supplies; prescribers could not see supplies from other pharmacies or the GP record, while inaccurate and insufficiently structured ward records obscured risk and care activity |
| Human-factors issue | Prescribers relied on patient-supplied history and consent; staff repeatedly updated plans without synthesising the known medication-procurement risk |
| Workflow issue | No cross-provider alert or mandatory information route existed; post-leave assessments were subsumed in Day Notes and observation/search documentation was not reliably auditable |
| Information issue | Medication supply, mental-health status and prior risk were fragmented; consent information was inaccurate and structured event evidence was missing |
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.