Ethel Robertson
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-202 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2025-0584 |
| Registered primary source | SRC-202 |
| Report date | 2025-11-17 |
| Coroner area | Hampshire, Portsmouth and Southampton |
| Clinical setting | Emergency department and community older-person mental-health care |
| Care transition | ED attendance and discharge to community mental-health follow-up |
| Primary workflow group | Record access and continuity |
| Primary browsing context | Cross-setting and multi-agency 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, Secondary acute or outpatient care, Primary care |
| Information or work-item origin | Secondary acute or outpatient care |
| Origin care context(s) | Secondary care |
| Expected action destination | Community mental-health care |
| Destination care context(s) | Community care |
| Directional pathway | Secondary acute or outpatient care → Community mental-health care |
| Care-setting span | Multiple care settings |
| Sector boundary | Health services only |
| Failure point | Transfer or interface |
| Classification confidence | high |
Classification note: An ED physical-health event needed to reach the existing community mental-health service, with primary care otherwise acting as an unreliable relay.
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-257 |
| Non-exclusive mechanism codes | LOOP, GOV, VIS, INT |
Qualification recorded in the dataset: The report frames the computer-system and notification gap as prospective risk; it does not state that it caused this death. The successor Trust's response identifies reliable flagging and notification, rather than the existence of different systems alone, as the main issue
“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 access and notification gap could delay follow-up, risk management and decision-making
Requested action
Southern Health Foundation Trust, now Hampshire and Isle of Wight Healthcare NHS Foundation Trust, to address cross-provider notification
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Separate hospital and community-provider computer systems |
| Digital function | Cross-provider attendance, record and discharge visibility |
| Failure mode | ED clinicians could not access community systems and the older-person mental-health team was not routinely informed of physical-health admissions or discharges |
| Human-factors issue | Whether community follow-up occurred depended on staff recognising a mental-health link or primary care manually relaying discharge information |
| Workflow issue | No reliable notification or shared-access route connected a physical-health crisis to the accountable community mental-health team |
| Information issue | The community team could remain unaware of an event capable of precipitating mental-health decline |
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.