Anthony Binfield; David Richards; Rolandas Karbauskas
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-074 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2025-0079 |
| Registered primary source | SRC-074 |
| Report date | 2025-02-07 |
| Coroner area | Nottingham City and Nottinghamshire |
| Clinical setting | Prison and secure healthcare |
| Care transition | Prison transfer and provider mobilisation |
| Primary workflow group | Risk, care planning and safeguarding |
| Primary browsing context | Secure and custodial care |
| Predominant information boundary | Across health and non-health sectors |
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 | Prison, custody or secure healthcare, Police, local authority or other non-health agency |
| Information or work-item origin | Multiple settings or services |
| Origin care context(s) | Secure or custodial healthcare, Non-health agency |
| Expected action destination | Multiple settings or services |
| Destination care context(s) | Secure or custodial healthcare, Non-health agency |
| Directional pathway | Multiple settings or services → Multiple settings or services |
| Care-setting span | Multiple care settings |
| Sector boundary | Health and non-health sectors |
| Failure point | Multiple points |
| Classification confidence | high |
Classification note: Risk information and action were distributed across prison healthcare, operational prison records and provider-transition workflows; origins, recipients and failure loci spanned health and custodial operations.
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, PROV, HF, RES, GOV |
Qualification recorded in the dataset: One clustered PFD covering three deaths; jury found multiple failings probably more than minimally contributed, but the digital component cannot be separated from severe staffing, culture and contract-transfer failures
“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
There was a complete failure to identify and share risk-pertinent information, including during prison and provider transitions
Requested action
HMPPS, NHS England and prison/healthcare providers to act
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | P-NOMIS, SystmOne, paper core files and email |
| Digital function | Suicide-risk identification, sharing and transfer |
| Failure mode | Risk information was not routinely read or updated across prison and healthcare systems; paper files went to storage and concerns were sent to individual inboxes not routinely monitored |
| Human-factors issue | Overburdened staff relied on current presentation and memory without a rapid coherent risk view |
| Workflow issue | Risk work was siloed; inboxes lacked team visibility; transfer requests lacked response times and escalation |
| Information issue | Prior self-harm, vulnerability and contemporaneous triggers were fragmented across paper, electronic records and email |
Downstream Defence trace
Canonical candidate requirements that cite this report: REQ-013. 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.