Elise Sebastian
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-192 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2026-0078 |
| Registered primary source | SRC-192 |
| Report date | 2026-02-08 |
| Coroner area | Essex |
| Clinical setting | Child and adolescent mental-health inpatient care |
| Care transition | Therapeutic observation and medication plan to ward care and post-death review |
| Primary workflow group | Triage, observations and decision support |
| Primary browsing context | Mental health care |
| Predominant information boundary | Within a care setting |
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 | Inpatient or secure mental-health care |
| Information or work-item origin | Inpatient or secure mental-health care |
| Origin care context(s) | Secondary care |
| Expected action destination | Inpatient or secure mental-health care |
| Destination care context(s) | Secondary care |
| Directional pathway | Inpatient or secure mental-health care → Inpatient or secure mental-health care |
| Care-setting span | One care setting |
| Sector boundary | Health services only |
| Failure point | Multiple points |
| Classification confidence | high |
Classification note: Monitoring, documentation, medication and audit failures were distributed across functions within one inpatient mental-health setting.
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-237 |
| Non-exclusive mechanism codes | LOOP, GOV, HF, ALERT, PROV, RES |
Qualification recorded in the dataset: The jury found observation failures and neglect contributed to death; the report contains numerous staffing, environmental, medication and governance factors, so no single technology is treated as the sole cause
“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
Technology rollout, record integrity, training and oversight failures remained capable of exposing highly vulnerable patients to fatal risk
Requested action
Essex Partnership University NHS Foundation Trust to address the identified observation, system, record-integrity and governance failures
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Oxevision, ward Wi-Fi, Datix and medication and observation records |
| Digital function | Observation monitoring, incident reporting, medicines documentation and audit |
| Failure mode | Oxevision and Wi-Fi did not work reliably, interim safeguards and Datix reports failed, medication changes were omitted and observation records were falsified or inconsistent |
| Human-factors issue | Unworkable observation workload, incomplete training and unreliable alerts encouraged unsafe workarounds and inaccurate recording |
| Workflow issue | Project oversight did not reconcile known connectivity faults, missing Datix reports, monitor coverage, medication charts or observation evidence |
| Information issue | Live monitoring, incident state, medication and recorded observations did not form a trustworthy or complete safety 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.