Melanie Walker
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-205 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2025-0529 |
| Registered primary source | SRC-205 |
| Report date | 2025-10-17 |
| Coroner area | Manchester West |
| Clinical setting | Emergency department resuscitation care |
| Care transition | Bedside ECG monitoring to emergency clinical response |
| Primary workflow group | Triage, observations and decision support |
| Primary browsing context | Acute and emergency 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 | Secondary acute or outpatient care |
| Information or work-item origin | Secondary acute or outpatient care |
| Origin care context(s) | Secondary care |
| Expected action destination | Secondary acute or outpatient care |
| Destination care context(s) | Secondary care |
| Directional pathway | Secondary acute or outpatient care → Secondary acute or outpatient care |
| Care-setting span | One care setting |
| Sector boundary | Health services only |
| Failure point | Receiving or action service |
| Classification confidence | high |
Classification note: Monitoring and response occurred within one emergency department; the locally configured alert did not remain actionable to staff.
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-260, SRC-261, SRC-262 |
| Non-exclusive mechanism codes | GOV, HF, ALERT, RES |
Qualification recorded in the dataset: The cardiac event was not observed and the precise reason the alarm did not trigger could not be established. Philips says the factory default was a persistent medium-priority yellow alarm and that the site had changed it to low-priority cyan; when and by whom was unclear. The risk therefore concerns local configuration and governance as well as alarm presentation, not a product-wide default defect
“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 local alarm configuration could leave an unobserved patient disconnected from monitoring
Requested action
Philips, NHS England and the Department of Health and Social Care to address configuration, awareness and mitigation of lead-disconnection alerts
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Philips physiological monitor with a locally configured alarm priority |
| Digital function | Lead-disconnection detection and persistent alerting |
| Failure mode | At the hospital, a disconnected ECG lead produced a locally configured low-priority cyan alert that could be acknowledged once without re-alerting while the fault persisted |
| Human-factors issue | A busy resuscitation environment and an alert that resembled an abnormal-reading acknowledgement made persistent disconnection easy to miss |
| Workflow issue | The local alarm configuration did not maintain a persistent or escalating indication until the lead was restored |
| Information issue | The system ceased producing a reliable heart trace without maintaining an actionable fault state under the local configuration |
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.