Jillian Steedman
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-207 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2025-0506 |
| Registered primary source | SRC-207 |
| Report date | 2025-10-10 |
| Coroner area | Essex |
| Clinical setting | Mental-health hospital, community mental health and care home |
| Care transition | Inpatient discharge plan to community and care-home risk management |
| Primary workflow group | Risk, care planning and safeguarding |
| Primary browsing context | Mental health care |
| Predominant information boundary | Between care settings |
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, Community mental-health care, Social care, care home or supported living, Police, local authority or other non-health agency |
| Information or work-item origin | Multiple settings or services |
| Origin care context(s) | Secondary care, Community care, Social care, Non-health agency |
| Expected action destination | Multiple settings or services |
| Destination care context(s) | Community care, Social care |
| Directional pathway | Multiple settings or services → Multiple settings or services |
| Care-setting span | Multiple care settings |
| Sector boundary | Health, social care and other non-health sectors |
| Failure point | Multiple points |
| Classification confidence | high |
Classification note: Risk and care information moved from hospital into community mental-health, social-care and local-authority activity; failures occurred during transfer, destination action and later documentation.
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-264, SRC-265 |
| Non-exclusive mechanism codes | LOOP, GOV, VIS, INT, PROV |
Qualification recorded in the dataset: The report identifies extensive clinical, placement and organisational failures; the post-death entry and record-transfer mechanisms are material strands rather than isolated causes
“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
Incomplete plans, failed crisis communication and unmarked late entry left severe suicide risk unmanaged and obscured review
Requested action
Essex Partnership University NHS Foundation Trust and Essex County Council to address discharge, risk and investigation failures
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Integrated plan, email and electronic mental-health record |
| Digital function | Care-plan transfer, crisis escalation and retrospective documentation |
| Failure mode | Required plans were not completed, crisis information did not reach the named teams and a risk assessment was added after death without retrospective marking |
| Human-factors issue | Visiting professionals assumed plans existed and did not challenge missing documents or reconcile newly recorded crises |
| Workflow issue | No accountable discharge and crisis workflow confirmed completion, receipt, escalation and review across teams |
| Information issue | Current risk, taxi-related vulnerability, crisis state and document chronology were incomplete or misleading |
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.