Miles Robinson
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-216 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2025-0340 |
| Registered primary source | SRC-216 |
| Report date | 2025-07-08 |
| Coroner area | South London |
| Clinical setting | Ambulance telephone triage |
| Care transition | 999 chest-pain call to ambulance dispatch |
| Primary workflow group | Triage, observations and decision support |
| Primary browsing context | Acute and emergency care |
| Predominant information boundary | Patient-to-service channel |
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 |
| Information or work-item origin | Patient or home |
| Origin care context(s) | Patient or public |
| Expected action destination | Ambulance, NHS 111 or urgent response |
| Destination care context(s) | Ambulance or urgent response |
| Directional pathway | Patient or home → Ambulance, NHS 111 or urgent response |
| Care-setting span | One care setting |
| Sector boundary | Health services only |
| Failure point | Receiving or action service |
| Classification confidence | high |
Classification note: Symptoms were reported from home and encoded by the receiving ambulance call-prioritisation system.
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 | No official response located |
| Registered response sources | None registered for this row |
| Non-exclusive mechanism codes | GOV, HF, ALERT |
Qualification recorded in the dataset: The ambulance service accepted that the first call's Category 3 coding was wrong. The inquest concluded natural causes and the report treats MPDS's separate Category 2 ceiling, together with demand context, as a prospective risk rather than a finding that the ceiling caused this death
“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
Protocol rigidity and categorisation could delay response to a conscious patient who arrests immediately after the call
Requested action
The Emergency Call Prioritisation Advisory Group and London Ambulance Service NHS Trust to address the identified triage risk
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Medical Priority Dispatch System |
| Digital function | Structured questioning and dispatch-code allocation |
| Failure mode | The first call was separately mis-triaged as Category 3 rather than Category 2; MPDS could not use the caller's statement that he was having a heart attack to raise a conscious, breathing chest-pain case beyond the protocol maximum of Category 2 to Category 1 |
| Human-factors issue | A non-clinical call handler was constrained by protocol branches even when the caller expressed a clear diagnostic concern |
| Workflow issue | No supported route incorporated clinically significant free information outside the determinant structure to exceed the Category 2 protocol ceiling |
| Information issue | The caller's belief could not alter disposition beyond Category 2; this limitation was distinct from the accepted erroneous Category 3 coding |
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.