Tracy McCarthy
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-072 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2024-0280 |
| Registered primary source | SRC-072 |
| Report date | 2024-05-21 |
| Coroner area | Inner North London |
| Clinical setting | Primary care/prescribing |
| Care transition | Hospital overdose information to repeat prescribing |
| Primary workflow group | Medication and prescribing |
| Primary browsing context | Primary and community 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, Primary care |
| Information or work-item origin | Secondary acute or outpatient care |
| Origin care context(s) | Secondary care |
| Expected action destination | Primary care |
| Destination care context(s) | Primary care |
| Directional pathway | Secondary acute or outpatient care → Primary care |
| Care-setting span | Multiple care settings |
| Sector boundary | Health services only |
| Failure point | Receiving or action service |
| Classification confidence | high |
Classification note: Hospital overdose information reached the practice, but the primary-care record did not convert it into a visible risk flag, medication review or preserved supply rationale.
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-102 |
| Non-exclusive mechanism codes | LOOP, GOV, VIS, HF, ALERT, PROV |
Qualification recorded in the dataset: Drug-related death; report identifies unsafe prescribing and absent flags but does not state that software design itself caused death; practice response identifies EMIS and proposed a coded risk-management care-plan register
“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
Acknowledged overdose and dependence risks were not recorded in a way that would alert any practitioner
Requested action
GP practice to act
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Practice prescribing/records software; response identifies EMIS |
| Digital function | Medication risk alerting and complex-care summary |
| Failure mode | Known dependence, overdose and prescribing risk were not placed in the record as a flag or alert, and amitriptyline prescribing continued with a 28-day supply |
| Human-factors issue | Clinicians unfamiliar with the patient depended on individual colleagues' memory and could not readily see the rationale for daily supply |
| Workflow issue | Hospital information did not trigger an owned medication review; safety depended on informal continuity with particular doctors |
| Information issue | Relevant risk existed in longitudinal notes but was not summarised or made salient |
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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