Francis Barnes
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-059 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2023-0417 |
| Registered primary source | SRC-059 |
| Report date | 2023-10-27 |
| Coroner area | Berkshire |
| Clinical setting | Private hospital/acute hospital/tertiary vascular network |
| Care transition | Private hospital to district general hospital to remote tertiary vascular hub |
| Primary workflow group | Referral, handover and transfer |
| 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 | Private healthcare provider, Secondary acute or outpatient care, Tertiary or specialist care |
| Information or work-item origin | Multiple settings or services |
| Origin care context(s) | Private healthcare, Secondary care, Tertiary or specialist care |
| Expected action destination | Multiple settings or services |
| Destination care context(s) | Secondary care, Tertiary or specialist 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: The emergency pathway traversed the private hospital, district general hospital and tertiary vascular network. Clinical information moved from private to secondary care, while specialist advice, referral decisions and transfer status moved between secondary and tertiary services. Telephone-only advice, missing records and unclosed referral ownership affected multiple points. This high confidence concerns pathway classification, not whether absence of an electronic referral system caused the death.
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 | medium |
| Verification status | Primary source linked; qualified extraction |
| Response evidence status | Response evidence noted |
| Registered response sources | SRC-082 |
| Non-exclusive mechanism codes | INT, LOOP, PROV, GOV |
Qualification recorded in the dataset: Delayed transfer and surgery contributed to death; the report did not find the absence of an electronic referral system causal. The response retained telephone referral for emergencies and proposed a Microsoft 365 documentation form
“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 noted that no records were made and sought pathway clarification, consideration of electronic referral and better learning from deaths
Requested action
Oxford University Hospitals NHS Foundation Trust to clarify vascular referral pathways, consider OARS or equivalent, and improve cross-organisational learning
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Telephone referral, EPR and proposed electronic referral/OARS |
| Digital function | Urgent specialist referral, advice documentation and transfer decision |
| Failure mode | Repeated specialist advice remained verbal and unrecorded; the cross-network emergency-referral route lacked a durable shared record |
| Human-factors issue | Time-critical verbal advice and differing clinical opinions lacked a shared representation |
| Workflow issue | Referral ownership, decision rationale and transfer outcome were not recorded or closed across organisations |
| Information issue | Advice, referral history and clinical disagreement were absent; an EPR-dependent option could not cover patients without an Oxford record |
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.