Theo Tuikubulau
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-070 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2026-0006 |
| Registered primary source | SRC-070 |
| Report date | 2026-01-06 |
| Coroner area | Devon, Plymouth and Torbay |
| Clinical setting | Telephone triage/ambulance |
| Care transition | 111/999 call to ambulance disposition |
| Primary workflow group | Triage, observations and decision support |
| Primary browsing context | Acute and emergency 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 | Patient or home, Ambulance, NHS 111 or urgent response |
| Information or work-item origin | Patient or home |
| Origin care context(s) | Patient or public |
| Expected action destination | Ambulance, NHS 111 or urgent response |
| Destination care context(s) | Ambulance or urgent response |
| Directional pathway | Patient or home → Ambulance, NHS 111 or urgent response |
| Care-setting span | One care setting |
| Sector boundary | Health services only |
| Failure point | Receiving or action service |
| Classification confidence | high |
Classification note: Respiratory symptoms were reported through 111 or 999 and required ambulance categorisation; the concern was route-dependent decision support within the receiving urgent-care service.
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-100, SRC-101 |
| Non-exclusive mechanism codes | ALERT, HF, GOV |
Qualification recorded in the dataset: Report raised a prospective system concern but did not isolate it as causal; later NHS England responses said both systems would reach category 1 when the full presentation was triaged appropriately and considered no system change necessary
“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
Two triage systems appeared to create inconsistent ambulance categorisation for a child with respiratory distress
Requested action
NHS England to review and ensure clinically appropriate consistency
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | NHS Pathways and Medical Priority Dispatch System |
| Digital function | Remote triage/ambulance categorisation |
| Failure mode | Similar reported respiratory distress and cyanosis could produce category 1 through MPDS but category 2 through NHS Pathways |
| Human-factors issue | Different scripted questioning and symptom elicitation could change acuity classification |
| Workflow issue | The access channel selected determined the decision-support pathway and disposition |
| Information issue | The same clinical description was encoded differently across triage systems |
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.