Tammy Milward
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-075 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2025-0027 |
| Registered primary source | SRC-075 |
| Report date | 2025-01-15 |
| Coroner area | Surrey |
| Clinical setting | Primary care/community mental health |
| Care transition | GP, pharmacy and GP integrated mental-health service |
| Primary workflow group | Risk, care planning and safeguarding |
| Primary browsing context | Cross-setting and multi-agency 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 | Pharmacy or dispensing service, Primary care, Community mental-health care, Patient or home |
| Information or work-item origin | Multiple settings or services |
| Origin care context(s) | Patient or public, Pharmacy |
| Expected action destination | Multiple settings or services |
| Destination care context(s) | Community care, Primary 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: Two distinct safety-relevant messages followed different paths: the patient's discharge message into the GP integrated mental-health service and the pharmacy's self-harm concern to the GP. Each was unavailable to the other accountable service, so origins, destinations and failure points are distributed across the patient, pharmacy, primary-care and community mental-health pathway.
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-104, SRC-105 |
| Non-exclusive mechanism codes | INT, VIS, LOOP, HF, GOV |
Qualification recorded in the dataset: Drug-related death; coroner framed EHR gap as future-death risk rather than a specific causal finding. Responses described Surrey Care Record mitigation and proposed telephone/email coordination pending integration
“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
Lack of coordination and communication between primary and secondary care could place patients at risk of early death
Requested action
Mental-health Trust and GP practice to act
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | EMIS and SystmOne |
| Digital function | Cross-sector record and risk-message sharing |
| Failure mode | The GP could not see SystmOne mental-health notes and GPimhs could not easily access EMIS records, so neither knew of the other's same-day high-risk message |
| Human-factors issue | Access friction and weak co-location/personal interaction left clinicians with partial situational awareness |
| Workflow issue | No reliable shared workflow reconciled the patient's discharge message and the pharmacy's self-harm concern |
| Information issue | Material messages were separately recorded and unavailable to the other accountable service |
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.