Valerie Gibson
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-043 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2025-0630 |
| Registered primary source | SRC-043 |
| Report date | 2025-12-17 |
| Coroner area | Sunderland |
| Clinical setting | Mental health inpatient care |
| Care transition | Dispensing to administration |
| Primary workflow group | Medication and prescribing |
| Primary browsing context | Mental health 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 | Inpatient or secure mental-health care |
| Information or work-item origin | Inpatient or secure mental-health care |
| Origin care context(s) | Secondary care |
| Expected action destination | Inpatient or secure mental-health care |
| Destination care context(s) | Secondary care |
| Directional pathway | Inpatient or secure mental-health care → Inpatient or secure mental-health care |
| Care-setting span | One care setting |
| Sector boundary | Health services only |
| Failure point | Multiple points |
| Classification confidence | high |
Classification note: Dispensing and administration states did not transfer consistently between Omnicell and ePMA inside the mental-health inpatient service, and safe use then depended on manual reconciliation by receiving staff. Both the system interface and destination checking workflow were material failure points.
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 | Not assessed in this dataset |
| Registered response sources | None registered for this row |
| Non-exclusive mechanism codes | INT, PROV, HF, GOV, LOOP |
Qualification recorded in the dataset: Coroner noted opportunity for harm; toxicology did not show additional ingestion
“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
Trust asked to review integration, practice and learning
Requested action
Trust to act
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Omnicell and ePMA |
| Digital function | Medication dispensing/administration |
| Failure mode | Separate systems produced contradictory records of dispensed and administered medicines |
| Human-factors issue | Workload encouraged pre-documentation; users held inconsistent mental models |
| Workflow issue | Correct use depended on manual reconciliation |
| Information issue | Stock, dispensing and administration states conflicted |
Downstream Defence trace
Canonical candidate requirements that cite this report: REQ-011. These links are analytical translations and do not make the requirement a coronial recommendation or a validated Defence control.
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.