Thomas Mallinson
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-218 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2025-0333 |
| Registered primary source | SRC-218 |
| Report date | 2025-06-30 |
| Coroner area | Cumbria |
| Clinical setting | NHS 111, ambulance and out-of-hours primary care |
| Care transition | Repeated urgent calls and 999 referral to out-of-hours clinician response |
| Primary workflow group | Triage, observations and decision support |
| Primary browsing context | Acute and emergency 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 | Patient or home, Ambulance, NHS 111 or urgent response, Primary care |
| Information or work-item origin | Multiple settings or services |
| Origin care context(s) | Patient or public, Ambulance or urgent response |
| Expected action destination | Multiple settings or services |
| Destination care context(s) | Ambulance or urgent response, 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: Repeated patient contacts entered ambulance and out-of-hours primary-care workflows, with an unresolved referral crossing between them.
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-278, SRC-279, SRC-280, SRC-281 |
| Non-exclusive mechanism codes | LOOP, GOV, INT, ALERT, RES |
Qualification recorded in the dataset: The narrative conclusion found significant delay amounting to neglect was a major causal factor; the digital and organisational mechanisms were interdependent. The response published as 'NHS Services' is printed 27 July 2024 and calls the PFD 20 June 2025; both dates conflict with the 30 June 2025 report and are treated as response-document anomalies
“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
The patient fell through an overcomplex system with no alert for repetition or failed inter-agency handoff
Requested action
SSP Health, Cumbria Health, North West Ambulance Service NHS Trust and the Department of Health and Social Care to address ownership, repeat-contact and escalation gaps
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Electronic referral, NHS call-handling systems and OPEL escalation process |
| Digital function | Repeated-contact alerting, referral ownership and callback escalation |
| Failure mode | The electronic referral was not acted on and there was no alert for repeated contacts or for a 999 case passed to another agency but left unresolved |
| Human-factors issue | Overloaded overnight clinicians could not triage the queue while visiting patients and call handlers lacked a cumulative view |
| Workflow issue | No closed loop returned responsibility to the ambulance service or escalated overdue callback work |
| Information issue | Repeated deterioration and the unresolved two-hour referral were not presented as one escalating patient state |
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.