Stephen Stringer
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-014 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2024-0555 |
| Registered primary source | SRC-014 |
| Report date | 2024-10-15 |
| Coroner area | Manchester South |
| Clinical setting | Primary care |
| Care transition | Patient digital channel to practice |
| Primary workflow group | Messaging, tasking and follow-up |
| Primary browsing context | Primary and community care |
| Predominant information boundary | Patient-to-service channel |
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, Primary care |
| Information or work-item origin | Patient or home |
| Origin care context(s) | Patient or public |
| Expected action destination | Primary care |
| Destination care context(s) | Primary care |
| Directional pathway | Patient or home → Primary care |
| Care-setting span | One care setting |
| Sector boundary | Health services only |
| Failure point | Transfer or interface |
| Classification confidence | high |
Classification note: Safety-relevant information submitted by the patient entered an administrative practice route but did not transfer into the clinical record or reach a clinician.
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-023 |
| Non-exclusive mechanism codes | LOOP, VIS, HF, PROV, GOV |
Qualification recorded in the dataset: This identifies the previously provisional Derby digital-enquiry case
“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
Digital enquiries and longitudinal action plans required safer design
Requested action
DHSC and Derby/Derbyshire ICB to act
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Electronic patient enquiry and EPR |
| Digital function | Messaging/continuity |
| Failure mode | Administrative-stream messages did not enter the record or reach a clinician |
| Human-factors issue | Headings did not make recipient pathway clear to patients |
| Workflow issue | Routing ownership and clinical escalation were unclear |
| Information issue | Patient-supplied information absent from clinical record |
Downstream Defence trace
Canonical candidate requirements that cite this report: REQ-005. These links are analytical translations and do not make the requirement a coronial recommendation or a validated Defence control.
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.