Alan Mitchell
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-203 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2025-0577 |
| Registered primary source | SRC-203 |
| Report date | 2025-11-10 |
| Coroner area | Cheshire |
| Clinical setting | Primary care |
| Care transition | Long-term medication plan to repeat-prescription maintenance |
| Primary workflow group | Medication and prescribing |
| Primary browsing context | Primary and community 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 | Primary care |
| Information or work-item origin | Primary care |
| Origin care context(s) | Primary care |
| Expected action destination | Primary care |
| Destination care context(s) | Primary care |
| Directional pathway | Primary care → Primary care |
| Care-setting span | One care setting |
| Sector boundary | Health services only |
| Failure point | Originating service |
| Classification confidence | high |
Classification note: The prescription lifecycle and missing notification operated within the primary-care record.
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 | medium |
| Verification status | Primary source linked; qualified extraction |
| Response evidence status | Response evidence noted |
| Registered response sources | SRC-258 |
| Non-exclusive mechanism codes | LOOP, GOV, ALERT, PROV |
Qualification recorded in the dataset: The coroner expressly stated that removal of the prescription played no causal part in this death. Optum's response disputes the reported default mechanism: it says repeat medication does not expire automatically unless an authorised user enables and configures that function, after which the item moves from Current to Past. The mechanism remains a recorded source disagreement
“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 coroner was concerned that silent alteration without clinician choice could deny essential medication, particularly for older patients or those with reserves
Requested action
Optum as EMIS supplier to address the repeat-medication expiry and notification concern
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | EMIS repeat-prescribing software |
| Digital function | Repeat-prescription lifecycle and clinician notification |
| Failure mode | The coroner heard evidence that EMIS removed a medicine after twelve months without an order and did not notify or seek authorisation from the GP |
| Human-factors issue | On the coroner's account, a silent automatic rule made the active list appear intentionally changed and required clinicians to notice and re-prescribe manually |
| Workflow issue | On the coroner's account, no alert, approval or review task accompanied removal of a long-term prescription |
| Information issue | The coroner reported that the repeat list no longer represented the intended lifelong treatment and did not expose why it had changed |
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.