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.