John Bell
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-212 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2025-0410 |
| Registered primary source | SRC-212 |
| Report date | 2025-08-04 |
| Coroner area | South Yorkshire East |
| Clinical setting | Acute hospital renal and spinal surgery |
| Care transition | Renal multidisciplinary-team decision to spinal pre-operative review |
| Primary workflow group | Record access and continuity |
| 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 renal and spinal teams were specialties within one acute hospital record environment.
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-272 |
| Non-exclusive mechanism codes | LOOP, GOV, VIS, HF |
Qualification recorded in the dataset: The coroner found that, had the renal finding been known, spinal surgery would not have proceeded then and the subsequent fatal sequence would probably have been avoided; the mechanism remains cross-specialty use of the record
“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
Critical clinical information was not available to or considered by surgeons before an operation
Requested action
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust to ensure critical cross-specialty information informs surgery
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Hospital electronic health record |
| Digital function | Cross-specialty visibility of diagnosis and treatment priority |
| Failure mode | The renal MDT note was apparently stored in the electronic record but the spinal surgical team did not know or consider it |
| Human-factors issue | A specialty team proceeded from its own working view without a salient competing cancer-treatment priority |
| Workflow issue | No pre-operative reconciliation required review of active MDT decisions from other specialties |
| Information issue | The renal tumour and proposed nephrectomy were electronically available but not visible in the spinal decision |
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.