Alan Peet
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-221 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2025-0609 |
| Registered primary source | SRC-221 |
| Report date | 2025-12-05 |
| Coroner area | Manchester South |
| Clinical setting | Nursing care home |
| Care transition | Agency nurse observations and medicines work to care-home record |
| Primary workflow group | Record integrity and provenance |
| 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 | Social care, care home or supported living |
| Information or work-item origin | Social care, care home or supported living |
| Origin care context(s) | Social care |
| Expected action destination | Social care, care home or supported living |
| Destination care context(s) | Social care |
| Directional pathway | Social care, care home or supported living → Social care, care home or supported living |
| Care-setting span | One care setting |
| Sector boundary | Social care only |
| Failure point | Originating service |
| Classification confidence | medium |
Classification note: The electronic care and medication entries were created and used inside one nursing care home; the source qualifies authorship as likely rather than certain.
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 | No official response located |
| Registered response sources | None registered for this row |
| Non-exclusive mechanism codes | GOV, HF, PROV, RES |
Qualification recorded in the dataset: The report says it was likely entries were made under another nurse's details and does not establish exactly who entered each item; the death also involved staffing, training and clinical-care failures
“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
Access-control failure and extremely poor notes prevented reconstruction of deterioration despite one-to-one care
Requested action
Acer Mews Care Home and the Care Quality Commission to address access, staffing oversight and record quality
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Care-home electronic care and medication systems |
| Digital function | Authenticated documentation, medicines access and audit provenance |
| Failure mode | The agency nurse lacked login rights and likely made entries under another nurse's credentials, making authorship impossible to untangle |
| Human-factors issue | Management knowingly placed a temporary worker into a role without the system access required to document care safely |
| Workflow issue | No resilient onboarding or downtime process preserved attributable recording for agency staff |
| Information issue | Observation, action and medication entries could not be reliably attributed to the person who made them |
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.