Lyn Maher
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-196 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2026-0053 |
| Registered primary source | SRC-196 |
| Report date | 2026-02-03 |
| Coroner area | South Wales Central |
| Clinical setting | Primary care and community pharmacy |
| Care transition | Medication and test history to pharmacy dispensing and counselling |
| Primary workflow group | Medication and prescribing |
| Primary browsing context | Primary and community 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 | Primary care, Pharmacy or dispensing service, Laboratory, radiology or diagnostic service |
| Information or work-item origin | Multiple settings or services |
| Origin care context(s) | Primary care, Diagnostic service |
| Expected action destination | Pharmacy or dispensing service |
| Destination care context(s) | Pharmacy |
| Directional pathway | Multiple settings or services → Pharmacy or dispensing service |
| Care-setting span | Multiple care settings |
| Sector boundary | Health services only |
| Failure point | Receiving or action service |
| Classification confidence | high |
Classification note: Medication and result information held outside community pharmacy was required by pharmacists at the point of dispensing.
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-243 |
| Non-exclusive mechanism codes | GOV, VIS, INT, ALERT |
Qualification recorded in the dataset: The coroner stated that access to the drug history likely would have changed the outcome; other GP, pharmacy and hospital diagnostic failures also contributed
“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
Limited Welsh portal access prevented pharmacists from performing safe checks and probably affected the outcome
Requested action
The Welsh Minister for Health and Social Care, General Pharmaceutical Council and Digital Health and Care Wales to address clinical checks, confidentiality and record access
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Welsh Clinical Portal and community pharmacy systems |
| Digital function | Cross-sector medication-history and result access |
| Failure mode | Community pharmacists had only very limited portal access and could not routinely see the statin and recent results needed to recognise a contraindication |
| Human-factors issue | Pharmacists dispensed without the longitudinal drug picture available to equivalent services elsewhere |
| Workflow issue | No dependable access or reconciliation step supported clinical checks when someone other than the patient collected the medicine |
| Information issue | Current simvastatin therapy and relevant clinical results were unavailable at dispensing |
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.