Stuart Berry
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-199 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2026-0015 |
| Registered primary source | SRC-199 |
| Report date | 2026-01-12 |
| Coroner area | Essex |
| Clinical setting | Community mental health and prison healthcare |
| Care transition | Community and court suicide-risk information to prison reception and care |
| Primary workflow group | Risk, care planning and safeguarding |
| Primary browsing context | Secure and custodial care |
| Predominant information boundary | Across health and non-health sectors |
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, Prison, custody or secure healthcare, Police, local authority or other non-health agency |
| Information or work-item origin | Multiple settings or services |
| Origin care context(s) | Community care, Non-health agency |
| Expected action destination | Prison, custody or secure healthcare |
| Destination care context(s) | Secure or custodial healthcare |
| Directional pathway | Multiple settings or services → Prison, custody or secure healthcare |
| Care-setting span | Multiple care settings |
| Sector boundary | Health and non-health sectors |
| Failure point | Multiple points |
| Classification confidence | high |
Classification note: Community and court risk information required transfer into prison healthcare and operational supervision; both handover and receiving documentation failed.
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-249, SRC-250, SRC-251 |
| Non-exclusive mechanism codes | LOOP, GOV, VIS, HF, INT, PROV |
Qualification recorded in the dataset: The jury found gross failures in constant supervision and the report contains extensive training, environmental and staffing concerns; digital documentation is one material strand. The embedded report is signed 2026-01-12; the Judiciary page says 2025-12-01, before the stated 2025-12-05 inquest conclusion
“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
Comprehensive information-sharing, documentation, assessment and escalation failures indicated serious training and assurance deficits
Requested action
EPUT, HCRG, HMPPS and the Ministry of Justice to address record, care-planning, training, supervision and suicide-prevention concerns
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | SystmOne and prison operational records |
| Digital function | Suicide-risk documentation, care planning and escalation |
| Failure mode | Material suicide risk was not documented in SystmOne, electronic records were inadequate and information from community care did not reach prison decision-makers |
| Human-factors issue | Staff relied on transient presentation and incomplete documentation rather than the known longitudinal risk picture |
| Workflow issue | No reliable handover, urgent mental-health referral or quality-control process reconciled court, community and reception information |
| Information issue | Extreme suicide risk, care plans and assessments were absent or inconsistent in the receiving record |
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.