Margaret McNaughton
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-214 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2025-0397 |
| Registered primary source | SRC-214 |
| Report date | 2025-08-01 |
| Coroner area | The Black Country |
| Clinical setting | Ambulance, primary care and acute hospital prescribing |
| Care transition | Allergy history to emergency antibiotic prescribing |
| 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 | Primary care, Ambulance, NHS 111 or urgent response, Secondary acute or outpatient care |
| Information or work-item origin | Multiple settings or services |
| Origin care context(s) | Primary care, Ambulance or urgent response, Secondary care |
| Expected action destination | Secondary acute or outpatient care |
| Destination care context(s) | Secondary care |
| Directional pathway | Multiple settings or services → 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: Allergy assertions arose from the patient, paramedic, GP and prior hospital record and required reconciliation by the acute prescriber.
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-275 |
| Non-exclusive mechanism codes | GOV, VIS, HF, INT, ALERT, PROV |
Qualification recorded in the dataset: The coroner found gross failure in prescribing and that CWP access would have prevented penicillin administration; the report also records disputed source availability and wider policy failures
“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
Policy did not specify who must check which allergy sources, when or where the verification must be recorded
Requested action
Royal Wolverhampton NHS Trust to implement and assure a defined allergy-verification workflow
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Hospital EPR, Clinical Web Portal, GP record and ePMA |
| Digital function | Allergy reconciliation, source provenance and prescribing decision support |
| Failure mode | The EPR showed no known allergies while CWP and GP records showed penicillin allergy, and the prescriber did not consult or document those sources |
| Human-factors issue | A pre-clerking prescription was made before seeing the patient, with an apparently complete local allergy state and unclear responsibility for source checks |
| Workflow issue | No mandatory reconciliation required two sources, provenance documentation and confirmation before ePMA prescribing |
| Information issue | Conflicting allergy states existed without a visible authoritative source or completeness warning |
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.