Amy Cross
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-219 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2025-0531 |
| Registered primary source | SRC-219 |
| Report date | 2025-10-22 |
| Coroner area | Avon |
| Clinical setting | Police, court and prison healthcare |
| Care transition | Police and court clinical encounters to prison reception healthcare |
| Primary workflow group | Referral, handover and transfer |
| Primary browsing context | Secure and custodial care |
| Predominant information boundary | Across health and non-health sectors |
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 | Prison, custody or secure healthcare, Police, local authority or other non-health agency |
| Information or work-item origin | Multiple settings or services |
| Origin care context(s) | Secure or custodial healthcare, Non-health agency |
| Expected action destination | Prison, custody or secure healthcare |
| Destination care context(s) | Secure or custodial healthcare |
| Directional pathway | Multiple settings or services → Prison, custody or secure healthcare |
| Care-setting span | Multiple care settings |
| Sector boundary | Health and non-health sectors |
| Failure point | Transfer or interface |
| Classification confidence | high |
Classification note: Clinical care was delivered by separate providers in police custody, court and prison; the digital escort and medical information crossed operational custody boundaries.
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-282 |
| Non-exclusive mechanism codes | LOOP, GOV, INT, PROV |
Qualification recorded in the dataset: The jury concluded natural causes; the report identifies the record-transfer gap as future risk rather than finding it caused death. Page metadata gives 2025-10-22 while the report is signed 2025-10-20
“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 criminal-justice healthcare pathway lacked a system for transferring essential medical information between providers
Requested action
NHS England and custodial healthcare providers to establish reliable shared clinical information transfer
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Digital Person Escort Record and separate provider clinical records |
| Digital function | Custodial transfer of medicines, observations and withdrawal state |
| Failure mode | The escort record was not updated with medical interventions and no standard record was accessible across police, court and prison healthcare providers |
| Human-factors issue | Each clinician assessed the patient without a complete account of medicines and observations already recorded by other providers |
| Workflow issue | No shared or accountable handover required every provider to add and reconcile current clinical information during conveyance |
| Information issue | Prison healthcare did not know which withdrawal medicines or observations had occurred earlier that day |
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.
Return to all included reports · Open the corpus profile · Review assurance and uncertainty · Open the case–mechanism/evidence map