Ethel Reed
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-069 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2024-0076 |
| Registered primary source | SRC-069 |
| Report date | 2024-02-08 |
| Coroner area | East Riding and Hull |
| Clinical setting | Hospital discharge to community rehabilitation |
| Care transition | Acute inpatient ward to community rehabilitation |
| Primary workflow group | Record integrity and provenance |
| 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, Community health or rehabilitation |
| Information or work-item origin | Secondary acute or outpatient care |
| Origin care context(s) | Secondary care |
| Expected action destination | Community health or rehabilitation |
| Destination care context(s) | Community care |
| Directional pathway | Secondary acute or outpatient care → Community health or rehabilitation |
| Care-setting span | Multiple care settings |
| Sector boundary | Health services only |
| Failure point | Transfer or interface |
| Classification confidence | high |
Classification note: The amended discharge representation arose in the acute hospital and was used by community rehabilitation; author attribution and notification were lost at that boundary.
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-097, SRC-098, SRC-099 |
| Non-exclusive mechanism codes | PROV, VIS, INT, LOOP, HF, GOV |
Qualification recorded in the dataset: Lorenzo defect was not found causal. Responses clarify a full underlying audit trail existed; the defect concerned attribution in the immediate discharge letter presented and distributed to users
“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
Unattributed amendments could cause critical miscommunication and treatment delay after discharge
Requested action
Hull University Teaching Hospitals NHS Trust, NHS England, CQC and CSC as Lorenzo provider to act
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Lorenzo EPR Immediate Discharge Letter |
| Digital function | Discharge-summary amendment and provenance |
| Failure mode | Lorenzo did not auto-populate the author of changes made to an immediate discharge letter after finalisation |
| Human-factors issue | Recipients could not readily determine who made a post-finalisation decision or amendment |
| Workflow issue | Post-finalisation changes could pass into the next care setting without visible attribution or reliable notification |
| Information issue | Author identity and decision provenance were absent from the distributed discharge representation |
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.