Delwyn Preece
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-187 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2026-0165 |
| Registered primary source | SRC-187 |
| Report date | 2026-03-17 |
| Coroner area | South Yorkshire East |
| Clinical setting | Mental-health inpatient care |
| Care transition | Ward leave assessment to record and post-event investigation |
| Primary workflow group | Record integrity and provenance |
| 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 | Originating service |
| Classification confidence | high |
Classification note: Risk assessments, leave decisions and later investigation all concerned records created within the inpatient mental-health service.
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-229 |
| Non-exclusive mechanism codes | GOV, VIS, HF, PROV |
Qualification recorded in the dataset: The death followed unescorted leave and a series of undocumented assessments; the report does not isolate electronic-record design from wider clinical and documentation failures
“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
Poor documentation and misinterpreted retrospective entries undermined care and the patient-safety investigation
Requested action
Rotherham Doncaster and South Humber NHS Foundation Trust to address documentation and investigation competence
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Electronic mental-health record |
| Digital function | Risk documentation, retrospective-entry provenance and investigation review |
| Failure mode | Leave was repeatedly granted without documented assessment, later entries were not labelled retrospective and investigators unfamiliar with the system missed them |
| Human-factors issue | Late documentation and limited investigator system knowledge made the ordinary chronology appear more complete than it was |
| Workflow issue | No control required timely pre-leave assessment or ensured late entries were visible and understood during investigation |
| Information issue | The record did not reliably distinguish contemporaneous assessment from material added up to two days later |
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.
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