Lee Dryden
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-213 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2025-0402 |
| Registered primary source | SRC-213 |
| Report date | 2023-08-02 |
| Coroner area | South Yorkshire (West District) |
| Clinical setting | External imaging and acute hospital care |
| Care transition | Critical PET finding to responsible hospital consultant and patient recall |
| Primary workflow group | Diagnostic results and investigations |
| Primary browsing context | Cross-setting and multi-agency 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 | Laboratory, radiology or diagnostic service, Private healthcare provider, Secondary acute or outpatient care |
| Information or work-item origin | Laboratory, radiology or diagnostic service |
| Origin care context(s) | Diagnostic service |
| Expected action destination | Secondary acute or outpatient care |
| Destination care context(s) | Secondary care |
| Directional pathway | Laboratory, radiology or diagnostic service → Secondary acute or outpatient care |
| Care-setting span | Multiple care settings |
| Sector boundary | Health services only |
| Failure point | Transfer or interface |
| Classification confidence | high |
Classification note: The critical result arose with an external imaging provider and required acknowledged action by the acute hospital team.
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-273, SRC-274 |
| Non-exclusive mechanism codes | LOOP, GOV, HF, INT, ALERT, RES |
Qualification recorded in the dataset: The coroner found failure to contact the patient after the critical result was a gross failure and earlier hospital review would have preceded the fatal arrest; report ref 2025-0402 contains a report signed in 2023. Royal College guidance was referenced in the concern but no Royal College was an action recipient
“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
Guidance for reporting critical external imaging findings was not understood or embedded, allowing urgent information to remain unactioned
Requested action
The Department of Health and Social Care and NHS England to embed reliable external critical-result communication
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Email, attached imaging report and text messaging |
| Digital function | Critical diagnostic-result notification and escalation |
| Failure mode | The email was not marked urgent and initially omitted the report; a consultant's text request was not seen until the following morning |
| Human-factors issue | The sender relied on subject wording and individual inboxes while the consultant considered a false positive and delegated contact near the end of the day |
| Workflow issue | No closed-loop critical-result route required attachment completeness, acknowledgement, patient contact and escalation |
| Information issue | A displaced tracheostomy tube was known in one service but did not reach an accountable, continuously monitored action queue |
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.