Gloria Simon
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-204 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2025-0554 |
| Registered primary source | SRC-204 |
| Report date | 2025-10-31 |
| Coroner area | Liverpool and Wirral |
| Clinical setting | Care home and primary care |
| Care transition | Care-home observations and history to GP remote assessment |
| Primary workflow group | Record access and continuity |
| Primary browsing context | Primary and community 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 | Social care, care home or supported living, Primary care |
| Information or work-item origin | Social care, care home or supported living |
| Origin care context(s) | Social care |
| Expected action destination | Primary care |
| Destination care context(s) | Primary care |
| Directional pathway | Social care, care home or supported living → Primary care |
| Care-setting span | Multiple care settings |
| Sector boundary | Health and social care |
| Failure point | Receiving or action service |
| Classification confidence | high |
Classification note: The care home supplied observations and history for a primary-care decision; the receiving GP system contained a flag that was not used.
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-259 |
| Non-exclusive mechanism codes | GOV, VIS, HF, PROV |
Qualification recorded in the dataset: The evidence did not establish whether GP attendance, closer monitoring or hospital admission would have changed the outcome. The undated practice response says the care home's request form itself called Riversdale a nursing home and records subsequent form and induction changes; this is relevant context for, but does not erase, the coroner's concerns about review of the available information
“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
Available record information and institutional context were not reliably used to assess a vulnerable resident
Requested action
Marine Lake Medical Practice to improve information, recording and remote clinical assessment
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Typed request form and GP practice record system |
| Digital function | Clinical-context flagging and remote review |
| Failure mode | The GP misread oxygen saturation, misunderstood the care setting and did not consult history that had been supplied and flagged in the practice system |
| Human-factors issue | Remote assessment, similar numerical values and an incorrect assumption that nurses were present reduced attention to available context |
| Workflow issue | No structured verification required review of the setting, timing of observations, prior history or clinical qualifications before disposition |
| Information issue | An oxygen saturation of 84 percent, care-home capability and relevant history were available but not integrated into the decision |
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.