Michael Nye
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-044 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2024-0082 |
| Registered primary source | SRC-044 |
| Report date | 2024-02-13 |
| Coroner area | Berkshire |
| Clinical setting | Emergency department |
| Care transition | Laboratory/external imaging to ED |
| Primary workflow group | Diagnostic results and investigations |
| Primary browsing context | Acute and emergency 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, Laboratory, radiology or diagnostic service |
| Information or work-item origin | Multiple settings or services |
| Origin care context(s) | Diagnostic service, Secondary care |
| Expected action destination | Multiple settings or services |
| Destination care context(s) | Diagnostic service, Secondary 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 report explicitly combines two opposite-direction flows: delayed laboratory results to the emergency department and a burdensome external CT request from the emergency department, with ineffective night escalation. Origins, destinations and failure points are therefore multiple across diagnostic and secondary-care contexts.
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 | LOOP, GOV, HF, ALERT, RES |
Qualification recorded in the dataset: Digital component is one of several coupled concerns
“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
Night-time result notification and external imaging workflow required action
Requested action
Hospital and pathology service to act
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Electronic Patient Record and external CT request process |
| Digital function | Results/imaging request |
| Failure mode | Night-time blood-result completion and notification were delayed; CT request process was burdensome |
| Human-factors issue | Busy night workflow and time-consuming external process |
| Workflow issue | Escalation pathways were ineffective at night |
| Information issue | Delayed result and request state |
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.
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