Jessica Smithson
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-211 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2025-0415 |
| Registered primary source | SRC-211 |
| Report date | 2025-08-08 |
| Coroner area | Manchester North |
| Clinical setting | Digital crisis-text mental-health support and police response |
| Care transition | Anonymous crisis text to emergency location and local mental-health pathways |
| Primary workflow group | Risk, care planning and safeguarding |
| Primary browsing context | Cross-setting and multi-agency 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, Community mental-health care, Police, local authority or other non-health agency |
| Information or work-item origin | Patient or home |
| Origin care context(s) | Patient or public |
| Expected action destination | Multiple settings or services |
| Destination care context(s) | Community care, Non-health agency |
| Directional pathway | Patient or home → Multiple settings or services |
| Care-setting span | Multiple care settings |
| Sector boundary | Health and non-health sectors |
| Failure point | Multiple points |
| Classification confidence | high |
Classification note: The user contacted a digital mental-health service that could require police location and local NHS follow-up; both health and non-health destinations were material.
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-269, SRC-270, SRC-271 |
| Non-exclusive mechanism codes | LOOP, GOV, INT, RES, IDPOP |
Qualification recorded in the dataset: The coroner found that police contact should have been made but would not have averted this death; the system concerns are prospective and service-wide. The crisis-text charity was an interested person and copy recipient, not an organisation directed to respond
“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
A high-volume national digital service lacked locally coordinated emergency and clinical pathways for users at real and immediate risk
Requested action
The Department of Health and Social Care, NHS England and Greater Manchester Integrated Care Board to address commissioning, police routing and local pathway integration
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | National crisis text platform and police referral arrangement |
| Digital function | Crisis communication, identity and location resolution, emergency referral |
| Failure mode | The service did not know the user's identity or location, did not contact police in this case and lacked integration with local NHS pathways |
| Human-factors issue | Text support could establish severe risk without the contextual information or local relationships needed to coordinate a rapid response |
| Workflow issue | The referral arrangement routed cases through the Metropolitan Police and provided no reliable local clinical handoff |
| Information issue | Identity, location, existing care-team status and local service options were unavailable when immediate action was considered |
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.