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 | INT, LOOP, VIS, 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.