Ruairi Stewart
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-190 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2026-0138 |
| Registered primary source | SRC-190 |
| Report date | 2026-03-10 |
| Coroner area | Cheshire |
| Clinical setting | Private residential mental-health hospital |
| Care transition | Ward care planning and handover to clinical review and investigation |
| Primary workflow group | Risk, care planning and safeguarding |
| Primary browsing context | Mental health care |
| Predominant information boundary | Hybrid paper and digital record |
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 | Private healthcare provider |
| Information or work-item origin | Private healthcare provider |
| Origin care context(s) | Private healthcare |
| Expected action destination | Private healthcare provider |
| Destination care context(s) | Private healthcare |
| Directional pathway | Private healthcare provider → Private healthcare provider |
| Care-setting span | One care setting |
| Sector boundary | Health services only |
| Failure point | Multiple points |
| Classification confidence | high |
Classification note: The material record and action failures occurred inside one private residential mental-health provider across several electronic and paper representations.
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-235 |
| Non-exclusive mechanism codes | LOOP, GOV, VIS, INT, PROV |
Qualification recorded in the dataset: The report describes numerous clinical, governance and disclosure failures; it makes no positive causal finding about fragmented records.
“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
Fragmented record keeping, weak ownership and poor-quality investigation left serious risks unaddressed
Requested action
Alternative Futures Group to address record, care-planning, handover and investigation failures
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Multiple electronic programmes and paper records |
| Digital function | Risk, care-plan, handover and disclosure record |
| Failure mode | Records were kept across multiple locations and media without a central clinical view, alongside inaccurate reports and missing handover information |
| Human-factors issue | Staff and investigators had to assemble risk state from fragmented and sometimes reassuring or incomplete records |
| Workflow issue | Tasks lacked named ownership and no single record supported care, handover, audit and disclosure |
| Information issue | Substance-use history, leave risk, tests and care-plan state were incomplete or inconsistent across representations |
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.