Emma Sanders
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-038 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2024-0646 |
| Registered primary source | SRC-038 |
| Report date | 2024-11-26 |
| Coroner area | Dorset |
| Clinical setting | Ambulance/emergency care |
| Care transition | Ambulance cohorting to hospital |
| Primary workflow group | Record access and continuity |
| 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 | Community mental-health care, Secondary acute or outpatient care, Ambulance, NHS 111 or urgent response |
| Information or work-item origin | Multiple settings or services |
| Origin care context(s) | Community care, Secondary care |
| 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 multi-provider care plan and hospital history were required by paramedics retaining responsibility during hospital cohorting and by the receiving acute service. Unavailable shared information and delayed transfer of clinical ownership affected both the interface and destination action, so destinations and failure points are coded as multiple.
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: SCR configuration varied by ICB in evidence
“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
Delay and missing care plans could affect care and create future risk
Requested action
NHS England and NHS Dorset to act
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Hospital record and Summary Care Record |
| Digital function | Record access/care plans |
| Failure mode | Paramedics in cohorting lacked hospital history and frequent-attender plan |
| Human-factors issue | Access depended on booking/triage and care plans were absent from SCR |
| Workflow issue | Receiving clinical ownership was delayed |
| Information issue | Relevant history and plan inaccessible |
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.