Rachelle Ross
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-002 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2023-0067 |
| Registered primary source | SRC-002 |
| Report date | 2023-02-17 |
| Coroner area | Newcastle upon Tyne and North Tyneside |
| Clinical setting | Primary care/screening |
| Care transition | National programme to GP |
| Primary workflow group | Screening and longitudinal surveillance |
| Primary browsing context | Primary and community care |
| Predominant information boundary | National-to-local information flow |
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 | National programme or service, Primary care |
| Information or work-item origin | National programme or service |
| Origin care context(s) | National programme or service |
| Expected action destination | Primary care |
| Destination care context(s) | Primary care |
| Directional pathway | National programme or service → Primary care |
| Care-setting span | One care setting |
| Sector boundary | Health services only |
| Failure point | Transfer or interface |
| Classification confidence | high |
Classification note: National screening non-responder status was not supplied to GP systems as computable data, leaving the local warning dependent on manual entry.
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-016, SRC-076, SRC-077, SRC-078 |
| Non-exclusive mechanism codes | LOOP, GOV, INT, ALERT, IDPOP |
Qualification recorded in the dataset: Vendor responses say due/outstanding smear alerts existed; the missing input was non-responder status
“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.
Registered counter-position or clarification
The records below preserve materially relevant differences, compatible clarifications, remedy counter-risks or documentary anomalies without adjudicating between the coroner and respondent by preference.
DIS-001 — Compatible clarification
Scope: Screening-alert and non-responder-state representation
Neutral account: Respondents narrow the coroner's concern to missing computable non-responder status rather than absence of all screening alerts.
Sources: primary SRC-002; response SRC-016, SRC-076, SRC-077, SRC-078.
Qualification: Generic due or outstanding smear alerts and separate worklists do not establish that national non-responder status was supplied into the EPR as computable data.
Open the complete counter-position register.
Structured project extraction
These fields are analytical summaries, not quotations.
Project summary of the coroner's concern
Automatic non-responder warning could standardise practice and improve safety
Requested action
Vendors, NHS Digital and government to act
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | National Screening Service feed, EMIS and SystmOne |
| Digital function | Screening recall |
| Failure mode | National Screening Service non-responder status was not automatically supplied as computable data; a warning depended on manual entry |
| Human-factors issue | Non-response status remained operationally inconspicuous despite existing due/outstanding smear alerts |
| Workflow issue | Safety net depended on manual local entry |
| Information issue | Missing non-responder status feed |
Downstream Defence trace
Canonical candidate requirements that cite this report: REQ-001, REQ-002, REQ-009. 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.
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