Samuel Jordan
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-021 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2024-0056 |
| Registered primary source | SRC-021 |
| Report date | 2024-02-02 |
| Coroner area | England |
| Clinical setting | Prison reception/primary care |
| Care transition | Temporary GP to prison healthcare |
| Primary workflow group | Identity and population management |
| Primary browsing context | Secure and custodial 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 | Primary care, Prison, custody or secure healthcare |
| Information or work-item origin | Primary care |
| Origin care context(s) | Primary care |
| Expected action destination | Prison, custody or secure healthcare |
| Destination care context(s) | Secure or custodial healthcare |
| Directional pathway | Primary care → Prison, custody or secure healthcare |
| Care-setting span | Multiple care settings |
| Sector boundary | Health services only |
| Failure point | Transfer or interface |
| Classification confidence | high |
Classification note: Recent treatment information arose in the temporary-GP record and was required by prison healthcare; record selection through Spine exposed the wrong primary-care source.
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 | IDPOP, INT, VIS, GOV |
Qualification recorded in the dataset: Direct DPHC/CORTISONE analogue
“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
Missing recent treatment and medication contributed to incomplete assessment
Requested action
Prison and national recipients to act
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | NHS Spine and GP registration |
| Digital function | Record location/transfer |
| Failure mode | Spine supplied the permanent-GP record rather than the recent temporary-practice record containing mental-health treatment |
| Human-factors issue | Administrative registration implied a falsely complete longitudinal view |
| Workflow issue | Reception workflow did not reconcile recent care sources |
| Information issue | Recent record inaccessible |
Downstream Defence trace
Canonical candidate requirements that cite this report: REQ-001, REQ-002, REQ-003. 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.