James Cochrane
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-209 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2025-0454 |
| Registered primary source | SRC-209 |
| Report date | 2025-09-05 |
| Coroner area | Rutland and North Leicestershire |
| Clinical setting | Community mental-health care |
| Care transition | Family-supplied evidence and carer views to risk assessment and safety planning |
| Primary workflow group | Risk, care planning and safeguarding |
| Primary browsing context | Mental health 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 |
| Information or work-item origin | Patient or home |
| Origin care context(s) | Patient or public |
| Expected action destination | Community mental-health care |
| Destination care context(s) | Community care |
| Directional pathway | Patient or home → Community mental-health care |
| Care-setting span | One care setting |
| Sector boundary | Health services only |
| Failure point | Receiving or action service |
| Classification confidence | medium |
Classification note: Video and family observations arose in the home and were offered to a community mental-health assessment; the exact SystmOne assurance path is not fully specified.
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; qualified extraction |
| Response evidence status | Response evidence noted |
| Registered response sources | SRC-267 |
| Non-exclusive mechanism codes | GOV, VIS, HF, PROV |
Qualification recorded in the dataset: The report contains extensive clinical-assessment and service concerns; mobile video and SystmOne assurance are future-risk issues and not isolated causal findings
“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
Unclear use of modern evidence formats and carer information could leave assessments and safety plans incomplete
Requested action
Leicestershire Partnership NHS Trust to clarify clinical use of video and assurance around carer information
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Mobile video and SystmOne |
| Digital function | Alternative-format evidence and carer-information capture |
| Failure mode | There was no clear guidance on using mobile video in assessment and no clear assurance that SystmOne carer-view entries informed follow-up safety plans |
| Human-factors issue | Clinicians unfamiliar with the baseline discounted family interpretation and questioned whether video evidence should be used |
| Workflow issue | No governed process required relevant multimedia and carer information to be reviewed, documented and reflected in the risk plan |
| Information issue | Evidence of episodic psychosis and family knowledge were not reliably incorporated into the clinical risk representation |
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.