Chloe Burgess
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-055 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2025-0121 |
| Registered primary source | SRC-055 |
| Report date | 2025-03-04 |
| Coroner area | England |
| Clinical setting | Primary care/community pharmacy |
| Care transition | Prescribing across primary and pharmacy care |
| 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 | Unclear |
| Origin care context(s) | Unclear |
| Expected action destination | Multiple settings or services |
| Destination care context(s) | Primary care, Pharmacy |
| Directional pathway | Unclear → Multiple settings or services |
| Care-setting span | Multiple care settings |
| Sector boundary | Health services only |
| Failure point | Multiple points |
| Classification confidence | medium |
Classification note: The report identifies the absence of an interaction alert across primary-care prescribing and community-pharmacy checking, but it does not support a single setting where the safety-relevant work item originated. Action was expected in both contexts, so destination and failure point are coded as multiple while origin remains unclear.
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 | ALERT, VIS, GOV |
Qualification recorded in the dataset: Primary report verified
“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
Absence of alert for the combination created future risk
Requested action
Practice, vendors and national bodies to act
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Prescribing software |
| Digital function | Drug-interaction decision support |
| Failure mode | Amitriptyline, paroxetine and ivabradine combination generated no software alert |
| Human-factors issue | Users could reasonably expect interaction support |
| Workflow issue | Knowledge-base gap left no machine safety barrier |
| Information issue | Interaction risk not surfaced |
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.