Emma Turner
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-191 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2026-0115 |
| Registered primary source | SRC-191 |
| Report date | 2026-02-25 |
| Coroner area | Derby and Derbyshire |
| Clinical setting | Primary care, adult social care and safeguarding |
| Care transition | GP and other agency concerns to adult safeguarding |
| Primary workflow group | Risk, care planning and safeguarding |
| Primary browsing context | Cross-setting and multi-agency 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, Social care, care home or supported living, Police, local authority or other non-health agency |
| Information or work-item origin | Multiple settings or services |
| Origin care context(s) | Primary care, Social care, Non-health agency |
| Expected action destination | Social care, care home or supported living |
| Destination care context(s) | Social care |
| Directional pathway | Multiple settings or services → Social care, care home or supported living |
| Care-setting span | Multiple care settings |
| Sector boundary | Health, social care and other non-health sectors |
| Failure point | Transfer or interface |
| Classification confidence | high |
Classification note: GP, social-care and local-authority safeguarding information needed to reach an accountable safeguarding service across health, care and agency 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; high-confidence extraction |
| Response evidence status | Response evidence noted |
| Registered response sources | SRC-236 |
| Non-exclusive mechanism codes | GOV, VIS, HF, INT, PROV |
Qualification recorded in the dataset: The conclusion identified long-standing clinical and social-care failures; the report presents system connectivity and template design as continuing risks rather than isolated causal findings
“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
Disconnected systems and an unsuitable referral template could delay safeguarding response for vulnerable adults
Requested action
Derby City Council and Derbyshire County Council to address system connectivity and safeguarding-referral information
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Separate agency information systems and safeguarding referral template |
| Digital function | Cross-agency record access and safeguarding referral capture |
| Failure mode | Systems lacked connectivity and the common safeguarding form did not elicit the information a GP needed to provide |
| Human-factors issue | One generic form presented questions designed for other agencies and obscured clinically relevant inputs |
| Workflow issue | No shared view or tailored referral route enabled agencies to understand prior intervention and non-attendance |
| Information issue | Clinical, social-care and safeguarding information remained partial and the referral could omit key GP concerns |
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.