Stephen Neville
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-220 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2025-0556 |
| Registered primary source | SRC-220 |
| Report date | 2025-10-24 |
| Coroner area | Essex |
| Clinical setting | Community and inpatient older-person mental-health care |
| Care transition | Community medicines and risk history to inpatient treatment and therapeutic observations |
| Primary workflow group | Triage, observations and decision support |
| Primary browsing context | Mental health 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 | Community mental-health care, Inpatient or secure mental-health care |
| Information or work-item origin | Multiple settings or services |
| Origin care context(s) | Community care, Secondary care |
| Expected action destination | Inpatient or secure mental-health care |
| Destination care context(s) | Secondary care |
| Directional pathway | Multiple settings or services → Inpatient or secure mental-health care |
| Care-setting span | Multiple care settings |
| Sector boundary | Health services only |
| Failure point | Multiple points |
| Classification confidence | high |
Classification note: Community medicines and risk history transferred into inpatient care, while the principal digital audit failure occurred in ward observation recording.
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-283 |
| Non-exclusive mechanism codes | LOOP, GOV, VIS, HF, PROV |
Qualification recorded in the dataset: Suicide was contributed to by neglect through numerous communication, medication, observation and environmental failures; electronic design and audit were explicit ongoing concerns but not the sole cause
“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
Digitisation had reproduced unsafe practice while removing qualitative audit, leaving highly vulnerable inpatients at risk
Requested action
Essex Partnership University NHS Foundation Trust to restore robust observation capture, audit and quality assurance
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Electronic therapeutic-observation record and mental-health clinical record |
| Digital function | Observation documentation, mandatory capture and quality audit |
| Failure mode | Electronic free text was optional and the audit tool no longer checked the nature and quality of therapeutic observations |
| Human-factors issue | Staff could complete location entries at fixed intervals without documenting meaningful engagement and management relied on nominal compliance scores |
| Workflow issue | No effective qualitative audit reconciled recorded observations with policy-required interaction and engagement |
| Information issue | The electronic record could appear complete while omitting the clinical substance needed to assess observation quality |
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.