Derek Crowther
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-208 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2025-0500 |
| Registered primary source | SRC-208 |
| Report date | 2025-10-09 |
| Coroner area | Manchester South |
| Clinical setting | Older-person mental-health inpatient care |
| Care transition | Ward observations to deterioration recognition |
| Primary workflow group | Triage, observations and decision support |
| Primary browsing context | Mental health 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 | Inpatient or secure mental-health care |
| Information or work-item origin | Inpatient or secure mental-health care |
| Origin care context(s) | Secondary care |
| Expected action destination | Inpatient or secure mental-health care |
| Destination care context(s) | Secondary care |
| Directional pathway | Inpatient or secure mental-health care → Inpatient or secure mental-health care |
| Care-setting span | One care setting |
| Sector boundary | Health services only |
| Failure point | Originating service |
| Classification confidence | high |
Classification note: The observations arose and were required for action within one older-person mental-health ward.
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-266 |
| Non-exclusive mechanism codes | GOV, VIS, PROV, RES |
Qualification recorded in the dataset: The inquest concluded natural causes; the report expressly frames the recording mechanism as prospective risk and does not state that it caused death
“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 absence of digital observation capture created future risk from timing errors and missed deterioration
Requested action
Pennine Care NHS Foundation Trust to address observation-recording capability
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Electronic patient record with manual observation recording |
| Digital function | Contemporaneous observations, timing and trend analysis |
| Failure mode | The ward had an EPR but no mechanism for contemporaneous digital observation recording |
| Human-factors issue | Manual and potentially unclear entries made accurate timing, error control and trend recognition harder |
| Workflow issue | Observation capture was not integrated into an accountable deterioration-monitoring workflow |
| Information issue | Observation timing and trends were not available in a reliable digital 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.