Lily Jahany
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-039 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2024-0273 |
| Registered primary source | SRC-039 |
| Report date | 2024-05-17 |
| Coroner area | Leicester City and South Leicestershire |
| Clinical setting | Mental health/community/private care |
| Care transition | Private and prior care to NHS crisis assessment |
| Primary workflow group | Record access and continuity |
| Primary browsing context | Mental health 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, Community mental-health care |
| Information or work-item origin | Private healthcare provider |
| Origin care context(s) | Private healthcare |
| Expected action destination | Community mental-health care |
| Destination care context(s) | Community care |
| Directional pathway | Private healthcare provider → Community mental-health care |
| Care-setting span | Multiple care settings |
| Sector boundary | Health services only |
| Failure point | Transfer or interface |
| Classification confidence | high |
Classification note: Material psychiatric history held by prior private clinicians was unavailable to the NHS crisis team assessing risk and deciding whether to discharge from crisis care.
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 | INT, VIS, LOOP, GOV |
Qualification recorded in the dataset: Coroner did not find the information failures more than minimally contributed to death
“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
Procedure did not clearly require information gathering before discharge from crisis assessment
Requested action
Trust to act
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | SystmOne and external records |
| Digital function | Record access/risk assessment |
| Failure mode | No single record and private-sector records were unavailable within SystmOne |
| Human-factors issue | Incomplete history could mislead risk assessment |
| Workflow issue | Teams still needed proactively to obtain information |
| Information issue | Fragmented mental-health history |
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.