Sebastian Daniels
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-050 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2023-0346 |
| Registered primary source | SRC-050 |
| Report date | 2023-09-22 |
| Coroner area | Greater Manchester |
| Clinical setting | Emergency, primary and mental health care |
| Care transition | ED discharge to GP |
| Primary workflow group | Diagnostic results and investigations |
| 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 | Secondary acute or outpatient care, Primary care |
| Information or work-item origin | Secondary acute or outpatient care |
| Origin care context(s) | Secondary care |
| Expected action destination | Primary care |
| Destination care context(s) | Primary care |
| Directional pathway | Secondary acute or outpatient care → Primary care |
| Care-setting span | Multiple care settings |
| Sector boundary | Health services only |
| Failure point | Multiple points |
| Classification confidence | high |
Classification note: The ED discharge information did not flag the severe result or request action, and the receiving practice then filed it through an administrative route without clinical review.
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 | VIS, ALERT, LOOP, HF |
Qualification recorded in the dataset: Primary report verified
“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
Abnormal results in discharge communication needed clear flagging and action
Requested action
Care organisations to act
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Electronic discharge summary and GP record |
| Digital function | Results/discharge |
| Failure mode | Severe triglyceride result appeared in discharge information without abnormal/action flag and was administratively filed |
| Human-factors issue | Critical value lacked salience and actionable context |
| Workflow issue | No accountable action request reached clinician |
| Information issue | Present but not identified for action |
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.