Jason Clemens
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-217 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2025-0336 |
| Registered primary source | SRC-217 |
| Report date | 2025-07-02 |
| Coroner area | Cornwall and the Isles of Scilly |
| Clinical setting | Renal unit and acute medical unit |
| Care transition | Renal medical plan and urgent prescription to AMU nursing administration |
| Primary workflow group | Medication and prescribing |
| 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 | Secondary acute or outpatient care |
| Information or work-item origin | Secondary acute or outpatient care |
| Origin care context(s) | Secondary care |
| Expected action destination | Secondary acute or outpatient care |
| Destination care context(s) | Secondary care |
| Directional pathway | Secondary acute or outpatient care → Secondary acute or outpatient care |
| Care-setting span | Multiple care settings |
| Sector boundary | Health services only |
| Failure point | Multiple points |
| Classification confidence | high |
Classification note: The order arose in the renal unit and required action before and after transfer to a distinct acute medical unit within the same hospital context.
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-277 |
| Non-exclusive mechanism codes | LOOP, GOV, VIS, HF, ALERT |
Qualification recorded in the dataset: The inquest found the seven-hour delay likely hastened death and contributed more than minimally. The PFD itself leaves alert availability and effect unresolved; the Trust response confirms that no digital sepsis alert was then available because Nervecentre could not support it and describes a planned e-Care alert. The response, not the PFD, supports the confirmed absence
“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
Uncertain pathways and unread electronic orders allowed repeated missed opportunities; the coroner queried digital escalation without finding that it would have altered this case
Requested action
Royal Cornwall Hospitals NHS Trust to complete safe pathways and address digital alerting raised in this and the earlier Jervis report
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Electronic prescribing and medicines administration system and clinical handover record |
| Digital function | Urgent antibiotic order, handover and overdue-action alerting |
| Failure mode | Nurses in both units did not read the immediate EPMA order and the requirement was omitted from handover; the PFD asked whether the digital sepsis alert raised in the earlier Jervis report had been introduced and, if not, whether it might have helped |
| Human-factors issue | Staff relied on verbal communication and ordinary review of multiple records during movement between units |
| Workflow issue | No closed-loop task required acknowledgement and administration of a without-delay prescription before or after transfer |
| Information issue | The urgent antibiotic requirement existed electronically but was not visible in the receiving workflow |
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.