Anthony Card
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-195 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2026-0068 |
| Registered primary source | SRC-195 |
| Report date | 2025-11-07 |
| Coroner area | Suffolk |
| Clinical setting | Police contact and community mental-health safeguarding |
| Care transition | Police risk report to medical and mental-health providers |
| Primary workflow group | Risk, care planning and safeguarding |
| Primary browsing context | Cross-setting and multi-agency 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 | Police, local authority or other non-health agency, Primary care, Community mental-health care |
| Information or work-item origin | Police, local authority or other non-health agency |
| Origin care context(s) | Non-health agency |
| Expected action destination | Multiple settings or services |
| Destination care context(s) | Primary care, Community care |
| Directional pathway | Police, local authority or other non-health agency → Multiple settings or services |
| Care-setting span | Multiple care settings |
| Sector boundary | Health and non-health sectors |
| Failure point | Transfer or interface |
| Classification confidence | medium |
Classification note: The police report was intended for whichever primary or mental-health provider held responsibility; the source does not identify one receiving 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-241, SRC-242 |
| Non-exclusive mechanism codes | LOOP, GOV, INT |
Qualification recorded in the dataset: The inquest did not establish that the absent route caused death; the report frames it as a prospective risk to later assessment and support
“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 missing referral route could deprive treating services of information needed to offer support and assess future risk
Requested action
Suffolk Constabulary and Suffolk County Council to establish a governed route for consensual mental-health risk information below safeguarding thresholds
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Police Protecting Vulnerable Persons report and Multi-Agency Safeguarding Hub workflow |
| Digital function | Consensual mental-health risk referral and sharing |
| Failure mode | Outside the Care Act section 42 threshold there was no mechanism for police to send medium-level mental-health risk to the person's care providers |
| Human-factors issue | Officers believed the PVP would communicate risk through MASH, but the agreed threshold silently prevented onward sharing |
| Workflow issue | No alternative route owned, acknowledged or delivered risk information when safeguarding criteria were not met |
| Information issue | In a future assessment, the recent police encounter and assessed self-harm risk could be unavailable to the treating clinicians |
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.