Thompson Elliott
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-206 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2025-0515 |
| Registered primary source | SRC-206 |
| Report date | 2025-10-14 |
| Coroner area | Sunderland |
| Clinical setting | Acute hospital discharge to care home |
| Care transition | Hospital medication change to care-home administration |
| Primary workflow group | Medication and prescribing |
| Primary browsing context | Cross-setting and multi-agency 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 | Secondary acute or outpatient care, Social care, care home or supported living |
| Information or work-item origin | Secondary acute or outpatient care |
| Origin care context(s) | Secondary care |
| Expected action destination | Social care, care home or supported living |
| Destination care context(s) | Social care |
| Directional pathway | Secondary acute or outpatient care → Social care, care home or supported living |
| Care-setting span | Multiple care settings |
| Sector boundary | Health and social care |
| Failure point | Multiple points |
| Classification confidence | high |
Classification note: Medication changes arose during hospital admission and required reconciliation and correct entry in the receiving care-home eMAR.
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-263 |
| Non-exclusive mechanism codes | LOOP, GOV, HF, INT, PROV |
Qualification recorded in the dataset: The dual-opioid administration caused an overdose; death followed influenza in a frail patient after treatment, so the report does not present the digital error as the sole cause of death. The Judiciary landing page dates the report 14 October 2025, while the embedded signed report is dated 15 October 2025
“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 procedure and incorrect eMAR recording caused an opioid overdose and continued a medicine stopped for renal harm
Requested action
Care UK to establish a clear discharge-medication reconciliation procedure
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Hospital discharge letter and care-home electronic medication administration record |
| Digital function | Medication reconciliation, replacement and administration |
| Failure mode | The discharge letter could not be found, old medication continued and replacement oxycodone was entered into eMAR as additional medication |
| Human-factors issue | Uncertainty and absence of a policy led staff to hold, delay and then misclassify the new medicine without resolving the discrepancy |
| Workflow issue | No closed-loop discharge reconciliation or escalation path established which opioid had stopped before administration |
| Information issue | The care-home medication view simultaneously represented old and replacement opioids as active |
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.