Colin Brown
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-201 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2025-0642 |
| Registered primary source | SRC-201 |
| Report date | 2025-12-23 |
| Coroner area | North Yorkshire and York |
| Clinical setting | Home care, ambulance and emergency department |
| Care transition | Care-plan and ambulance choking-risk information to ED care |
| Primary workflow group | Referral, handover and transfer |
| 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 | Social care, care home or supported living, Ambulance, NHS 111 or urgent response, Secondary acute or outpatient care |
| Information or work-item origin | Multiple settings or services |
| Origin care context(s) | Social care, Ambulance or urgent response |
| Expected action destination | Secondary acute or outpatient care |
| Destination care context(s) | Secondary care |
| Directional pathway | Multiple settings or services → Secondary acute or outpatient care |
| Care-setting span | Multiple care settings |
| Sector boundary | Health and social care |
| Failure point | Transfer or interface |
| Classification confidence | high |
Classification note: Choking-risk information arose in home care and the ambulance record and was required by the emergency department at handover.
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-255, SRC-256 |
| Non-exclusive mechanism codes | LOOP, GOV, VIS, HF, INT, RES |
Qualification recorded in the dataset: The report raises the approximately 25-minute upload blind period as a prospective handover risk, not as the operative cause of this event. The choking occurred about 90 minutes after handover and, according to the YAS response, more than 50 minutes after the ePR was available; YAS also states that swallowing difficulty was included in the verbal handover
“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
Routine delay and variable verbal handover could leave critical choking risk unavailable while care decisions were made
Requested action
York and Scarborough Teaching Hospitals NHS Foundation Trust and Yorkshire Ambulance Service to address handover reliability
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Paper care plan and ambulance electronic patient form uploaded to the Core Patient Database |
| Digital function | Emergency handover and choking-risk transfer |
| Failure mode | The care plan did not travel with the patient and the ePRF was unavailable during a routine upload delay after verbal handover |
| Human-factors issue | The patient could not reliably restate the risk and ED staff did not routinely ask for or check choking risk when unrelated to the presenting problem |
| Workflow issue | No bridge or mandatory handover item preserved safety-critical information during the electronic upload blind period |
| Information issue | The receiving ED lacked a timely, explicit statement that the patient required a modified diet because of choking risk |
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.