Myles Scriven
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-215 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2025-0357 |
| Registered primary source | SRC-215 |
| Report date | 2025-07-11 |
| Coroner area | West Yorkshire Western |
| Clinical setting | Acute hospital care |
| Care transition | Learning-disability adjustment assessment to ongoing ward care |
| Primary workflow group | Risk, care planning and safeguarding |
| Primary browsing context | Acute and emergency care |
| Predominant information boundary | Within a care setting |
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 | One care setting |
| Sector boundary | Health services only |
| Failure point | Receiving or action service |
| Classification confidence | high |
Classification note: The adjustment plan was created and required action by colleagues in the same acute hospital.
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; qualified extraction |
| Response evidence status | Response evidence noted |
| Registered response sources | SRC-276 |
| Non-exclusive mechanism codes | LOOP, GOV, VIS, HF |
Qualification recorded in the dataset: Neglect contributed to death through lack of adjustments; the EPR entry itself was accurate. Page metadata gives 2025-07-11 while the embedded report is signed 2025-07-14
“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
Existing people, training, passports and EPR entries had failed to produce compliance, and outcome audit remained insufficient
Requested action
Calderdale and Huddersfield NHS Foundation Trust, CQC North and NHS England to explain how full compliance and impact will be assured
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Electronic patient record |
| Digital function | Reasonable-adjustment documentation and clinical visibility |
| Failure mode | Accurate adjustment requirements were entered in the EPR but were not acted on after the author went on leave |
| Human-factors issue | Colleagues did not translate a specialist's clear entry into day-to-day decisions and relied on existing culture despite prior training and passports |
| Workflow issue | No accountable workflow ensured adjustment entries changed care or remained owned across staff absence |
| Information issue | The record held the required adjustments but they had no operational effect |
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.