Gareth Chumber-Kelly
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-193 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2026-0073 |
| Registered primary source | SRC-193 |
| Report date | 2026-02-09 |
| Coroner area | Inner North London |
| Clinical setting | Community mental health, court custody and prison healthcare |
| Care transition | Community and court risk information to prison reception and care |
| Primary workflow group | Referral, handover and transfer |
| 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 | Transfer or interface |
| Classification confidence | high |
Classification note: Mental-health risk arose before and during court custody and required reception by prison healthcare and operational staff across health and custodial boundaries.
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; qualified extraction |
| Response evidence status | Response evidence noted |
| Registered response sources | SRC-238, SRC-239 |
| Non-exclusive mechanism codes | LOOP, GOV, VIS, INT, PROV, RES |
Qualification recorded in the dataset: The jury identified inadequate medical-record review and continuity among multiple probable contributing failures; the report does not isolate the paper or email mechanism. The Judiciary page says 'North London', while the embedded signed PFD says 'Inner North London'.
“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
Recurrent loss of transfer paperwork and inadequate review of medical records exposed prisoners to foreseeable risk
Requested action
HMP Pentonville, Serco, the Secretary of State for Justice and the Minister for Prisons to address reception, document and suicide-prevention failures
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Paper liaison and transfer records with emailed copies |
| Digital function | Custodial transfer of mental-health and suicide-risk information |
| Failure mode | Important records accompanying the prisoner were lost or not reviewed and continuity information did not reach prison healthcare and operational staff |
| Human-factors issue | An inefficient, slow reception process relied on vulnerable paperwork and staff did not engage with known risk |
| Workflow issue | No accountable custody-transfer process confirmed receipt, review and action on the risk documentation |
| Information issue | Recent self-harm, suicide risk and required support were absent from the receiving prison's working 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.