Darryl Johnson
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-188 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2026-0152 |
| Registered primary source | SRC-188 |
| Report date | 2026-03-10 |
| Coroner area | Bedfordshire and Luton |
| Clinical setting | Ambulance emergency response |
| Care transition | 999 caller address to ambulance dispatch |
| Primary workflow group | Identity and population management |
| Primary browsing context | Acute and emergency care |
| Predominant information boundary | Patient-to-service channel |
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 | Patient or home, Ambulance, NHS 111 or urgent response |
| Information or work-item origin | Patient or home |
| Origin care context(s) | Patient or public |
| Expected action destination | Ambulance, NHS 111 or urgent response |
| Destination care context(s) | Ambulance or urgent response |
| Directional pathway | Patient or home → Ambulance, NHS 111 or urgent response |
| Care-setting span | One care setting |
| Sector boundary | Health services only |
| Failure point | Receiving or action service |
| Classification confidence | high |
Classification note: The caller supplied the location and the ambulance dispatch system resolved it incorrectly before crew attendance.
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-230 |
| Non-exclusive mechanism codes | GOV, HF, PROV, RES, IDPOP |
Qualification recorded in the dataset: The coroner said the patient might have been found alive at the correct address but it remained unclear whether death would have been avoided
“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
A long-established property remained absent from the dispatch database, creating ongoing emergency-response risk
Requested action
Ordnance Survey to address address-data accuracy and update controls
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Computer-aided dispatch using Ordnance Survey address and map data |
| Digital function | Address resolution and crew routing |
| Failure mode | CAD resolved the correct address supplied by the caller to a different neighbouring dwelling because the database was incomplete |
| Human-factors issue | The crew reasonably relied on the mapped address and closed the response after forced entry found nobody there |
| Workflow issue | No reliable exception or reconciliation path detected conflict between the caller's address and the mapped property |
| Information issue | The dispatch representation associated the patient with the wrong physical location |
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.