Jason Bayley
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-063 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2023-0392 |
| Registered primary source | SRC-063 |
| Report date | 2023-10-17 |
| Coroner area | Birmingham and Solihull |
| Clinical setting | Secure mental-health inpatient care |
| Care transition | Medication administration to ward handover and care planning |
| Primary workflow group | Medication and prescribing |
| Primary browsing context | Mental health care |
| Predominant information boundary | Within a care setting |
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 | Inpatient or secure mental-health care |
| Information or work-item origin | Inpatient or secure mental-health care |
| Origin care context(s) | Secondary care |
| Expected action destination | Inpatient or secure mental-health care |
| Destination care context(s) | Secondary care |
| Directional pathway | Inpatient or secure mental-health care → Inpatient or secure mental-health care |
| Care-setting span | One care setting |
| Sector boundary | Health services only |
| Failure point | Transfer or interface |
| Classification confidence | high |
Classification note: ePMA refusal data and Rio handover/care-planning views were used on the same secure mental-health ward; manual re-entry broke the transfer between them.
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-085 |
| Non-exclusive mechanism codes | PROV, INT, VIS, HF, LOOP, ALERT, GOV |
Qualification recorded in the dataset: Natural-causes conclusion; report did not quantify contribution of the record discrepancy. Response says missed lactulose contributed no more than minimally or trivially and proposed reconciliation controls
“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 Rio repeatedly stated that all medication had been taken when ePMA recorded refusals
Requested action
St Andrew's Healthcare to ensure accurate medication-adherence documentation and reduce future risk
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | ePMA, Rio EPR and EMIS physical-health record |
| Digital function | Medication administration, adherence display and shift handover |
| Failure mode | ePMA recorded lactulose refusals, but Rio working notes incorrectly stated on fourteen occasions that all medication had been taken |
| Human-factors issue | Staff creating shift notes were not always those administering medication; secondary transcription created an inaccurate familiar view |
| Workflow issue | Medication adherence was re-entered manually into Rio without reliable reconciliation against the authoritative ePMA record |
| Information issue | Contradictory medication-administration states existed across systems and views |
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.