Venetia Pierce
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-210 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2025-0427 |
| Registered primary source | SRC-210 |
| Report date | 2025-08-19 |
| Coroner area | Surrey |
| Clinical setting | Primary care prescribing |
| Care transition | National drug-safety knowledge to GP prescribing |
| Primary workflow group | Medication and prescribing |
| Primary browsing context | Primary and community care |
| Predominant information boundary | National-to-local information flow |
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 | National programme or service, Primary care |
| Information or work-item origin | National programme or service |
| Origin care context(s) | National programme or service |
| Expected action destination | Primary care |
| Destination care context(s) | Primary care |
| Directional pathway | National programme or service → Primary care |
| Care-setting span | One care setting |
| Sector boundary | Health services only |
| Failure point | Receiving or action service |
| Classification confidence | high |
Classification note: The national MHRA warning required implementation in a local primary-care prescribing workflow.
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 | medium |
| Verification status | Primary source linked; qualified extraction |
| Response evidence status | Response evidence noted |
| Registered response sources | SRC-268 |
| Non-exclusive mechanism codes | GOV, INT, ALERT |
Qualification recorded in the dataset: The report found nitrofurantoin-induced pneumonitis more likely than not led to death. EMIS's response says patient-specific warnings were displayed, including an age-related warning to monitor lung and liver function, and that MHRA alerts remained accessible through BNF and Safety Check. This counter-position qualifies, but does not erase, the coroner's concern about the specific alert presented in the prescribing workflow
“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
The coroner was concerned that limited awareness and conditional alerting could allow nitrofurantoin pulmonary toxicity to remain unrecognised
Requested action
The Medicines and Healthcare products Regulatory Agency and EMIS Health to address awareness and prescribing-alert coverage
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | MHRA drug-safety alert and EMIS prescribing system |
| Digital function | Nitrofurantoin pulmonary-risk decision support |
| Failure mode | The coroner reported that the MHRA warning did not appear in EMIS unless the patient already had pulmonary disease |
| Human-factors issue | On the coroner's account, prescribers could infer that absence of the specific warning meant no special pulmonary monitoring concern applied |
| Workflow issue | The report questioned whether national safety knowledge was translated into decision support for elderly patients without a pre-existing pulmonary diagnosis |
| Information issue | On the report's account, the prescribing view omitted the specific MHRA adverse-reaction alert for the patient's circumstances |
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.