Oliver Billings
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-042 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2024-0656 |
| Registered primary source | SRC-042 |
| Report date | 2024-11-28 |
| Coroner area | Devon, Plymouth and Torbay |
| Clinical setting | Primary care/pharmacy |
| Care transition | GP to online and local pharmacy |
| 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 | Primary care, Pharmacy or dispensing service |
| Information or work-item origin | Primary care |
| Origin care context(s) | Primary care |
| Expected action destination | Pharmacy or dispensing service |
| Destination care context(s) | Pharmacy |
| Directional pathway | Primary care → Pharmacy or dispensing service |
| Care-setting span | Multiple care settings |
| Sector boundary | Health services only |
| Failure point | Transfer or interface |
| Classification confidence | high |
Classification note: A GP cancellation did not reconcile prescription state after an online pharmacy had downloaded it, leaving duplicate active supply across pharmacy endpoints.
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 | LOOP, VIS, INT, RES |
Qualification recorded in the dataset: Strong distributed-transaction example
“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
Status should be ascertainable before a subsequent prescription is issued
Requested action
Practice, pharmacy body and online pharmacy to act
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Electronic Prescription Service |
| Digital function | Prescription cancellation |
| Failure mode | Cancellation occurred after one pharmacy had downloaded the prescription |
| Human-factors issue | Transaction state was not sufficiently visible before replacement issue |
| Workflow issue | Patient was asked to remedy cross-organisation failure |
| Information issue | Duplicate active supply across endpoints |
Downstream Defence trace
Canonical candidate requirements that cite this report: REQ-011. 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.
Return to all included reports · Open the corpus profile · Review assurance and uncertainty · Open the case–mechanism/evidence map