Bernard Compton
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-073 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2024-0304 |
| Registered primary source | SRC-073 |
| Report date | 2024-06-05 |
| Coroner area | Manchester South |
| Clinical setting | Ambulance/emergency department |
| Care transition | Ambulance triage to ED diagnosis and transfer |
| 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 | Patient or home, Ambulance, NHS 111 or urgent response, Laboratory, radiology or diagnostic service, Secondary acute or outpatient care |
| Information or work-item origin | Multiple settings or services |
| Origin care context(s) | Patient or public, Diagnostic service |
| Expected action destination | Multiple settings or services |
| Destination care context(s) | Ambulance or urgent response, 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 contains a patient-to-ambulance triage strand and a laboratory/ECG-to-ED action strand; independent failures occurred in urgent triage and acute result and repeat-test workflows.
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-103 |
| Non-exclusive mechanism codes | LOOP, GOV, HF, ALERT |
Qualification recorded in the dataset: Narrative conclusion linked delays in identifying MI to loss of treatment window; NHS England said NHS Pathways is non-diagnostic and NWAS considered category 3 appropriate for symptoms provided, so algorithm issue remains contested
“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.
Registered counter-position or clarification
The records below preserve materially relevant differences, compatible clarifications, remedy counter-risks or documentary anomalies without adjudicating between the coroner and respondent by preference.
DIS-006 — Material disagreement
Scope: Telephone-triage categorisation
Neutral account: The algorithm strand remains contested, separately from the unreviewed troponin and repeat-ECG failures.
Sources: primary SRC-073; response SRC-103.
Qualification: SRC-103 reports the ambulance service's view indirectly; it is not a direct ambulance-service response and does not resolve the other concerns in the report.
Open the complete counter-position register.
Structured project extraction
These fields are analytical summaries, not quotations.
Project summary of the coroner's concern
There was no clear urgent-result ownership or repeat-test monitoring system, and the call algorithm did not identify the time-critical presentation
Requested action
NHS England to act
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | NHS Pathways and hospital electronic results system |
| Digital function | Remote triage, critical results and repeat-test tasking |
| Failure mode | The call algorithm assigned category 3, a markedly raised troponin remained unreviewed for more than three hours, and a requested repeat ECG was not completed |
| Human-factors issue | Demand, night staffing and lack of oversight made passive result availability and memory-based follow-up unsafe |
| Workflow issue | No accountable process ensured urgent blood-result review or repeat ECG completion |
| Information issue | Time-critical MI evidence was present in the ECG/result system but not converted into action |
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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