Nigel Feckey
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-197 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2026-0047 |
| Registered primary source | SRC-197 |
| Report date | 2026-01-28 |
| Coroner area | Leicester City and South Leicestershire |
| Clinical setting | Prison custody and healthcare |
| Care transition | Prisoner, family and custodial messages to mental-health support |
| 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 | 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) | Non-health agency, Secure or custodial healthcare |
| Expected action destination | Multiple settings or services |
| Destination care context(s) | Non-health agency, Secure or custodial healthcare |
| Directional pathway | Multiple settings or services → Multiple settings or services |
| Care-setting span | One care setting |
| Sector boundary | Health and non-health sectors |
| Failure point | Multiple points |
| Classification confidence | high |
Classification note: Messages moved between the prisoner, custodial functions and prison healthcare inside one secure site; health and non-health roles were both material.
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 | medium |
| Verification status | Primary source linked; qualified extraction |
| Response evidence status | Response evidence noted |
| Registered response sources | SRC-244 |
| Non-exclusive mechanism codes | LOOP, GOV, VIS, HF, INT, RES |
Qualification recorded in the dataset: The digital mechanisms are explicit in the jury narrative and circumstances, but the formal Regulation 28 concern and requested action relate only to offence-neutrality policy; the report found the prisoner was primarily let down by the custodial system
“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
The formal Regulation 28 concern was the continuing national offence-neutrality policy and the risk it posed to prisoners convicted of sexual offences; the digital failures appear in the jury narrative, not the stated matter of concern
Requested action
Ministry of Justice to address the continuing offence-neutrality risk; no digital-system action was expressly requested
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Siloed paper and computer systems, email and prisoner kiosk application |
| Digital function | Risk communication, referral and team tasking |
| Failure mode | An urgent weekend email was unseen, a kiosk request was not passed to healthcare and information was siloed across custodial and clinical systems |
| Human-factors issue | Unstaffed inboxes, staffing pressure and divided responsibilities left messages appearing sent but not owned |
| Workflow issue | No cross-system route acknowledged, escalated or closed requests for mental-health help |
| Information issue | The prisoner's repeated distress and requests for support did not form a shared current risk picture |
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.