Elton Deutekom
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-068 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2024-0660 |
| Registered primary source | SRC-068 |
| Report date | 2024-12-02 |
| Coroner area | Inner West London |
| Clinical setting | Maternity/neonatal care and post-death review |
| Care transition | Community midwife to labour ward; handwritten notes to electronic record; obstetric care to medical examiner and pathologist |
| Primary workflow group | Triage, observations and decision support |
| Primary browsing context | Maternity and paediatric care |
| Predominant information boundary | Hybrid paper and digital record |
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 maternity care, Acute maternity or neonatal care, Laboratory, radiology or diagnostic service |
| 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) | Secondary care, Diagnostic service |
| 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 combines community-to-labour-ward transfer, live CTG action and acute-record provenance with obstetric information required by medical-examiner and pathology review; the paper/digital medium does not define the scope.
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-095, SRC-096 |
| Non-exclusive mechanism codes | VIS, LOOP, HF, PROV, INT, GOV |
Qualification recorded in the dataset: Reliance on the historic CTG and failure to escalate contributed to death; provenance and reviewer-access concerns were framed as future risks. Trust response says the note was accurately transcribed under policy before disposal and denies concealment
“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
Monitoring review, retrospective record integrity and access to obstetric records required preventive action
Requested action
Chelsea and Westminster NHS Foundation Trust, NHS England and the National Medical Examiner to act
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | CTG central monitoring board and hybrid handwritten/electronic maternity record |
| Digital function | Fetal monitoring, retrospective documentation and post-death record access |
| Failure mode | The current abnormal CTG was not recognised, no regular central-board review system existed, notes were entered retrospectively four to five hours later and the contemporaneous handwritten source was destroyed |
| Human-factors issue | A newly qualified midwife worked in an understaffed, busy ward and was distracted by administrative tasks; the registrar relied on the historic rather than current CTG trace |
| Workflow issue | No accountable regular CTG review occurred; retrospective transcription destroyed the original paper source; relevant obstetric information did not reliably reach reviewers |
| Information issue | Current CTG state, original-note provenance and relevant obstetric context were not reliably preserved or available |
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.