John Fisher
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-053 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2026-0166 |
| Registered primary source | SRC-053 |
| Report date | 2026-03-19 |
| Coroner area | England |
| Clinical setting | Community care |
| Care transition | Urgent community response to homecare |
| Primary workflow group | Medication and prescribing |
| Primary browsing context | Primary and community 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 | Community health or rehabilitation, Social care, care home or supported living |
| Information or work-item origin | Community health or rehabilitation |
| Origin care context(s) | Community care |
| Expected action destination | Social care, care home or supported living |
| Destination care context(s) | Social care |
| Directional pathway | Community health or rehabilitation → Social care, care home or supported living |
| Care-setting span | Multiple care settings |
| Sector boundary | Health and social care |
| Failure point | Transfer or interface |
| Classification confidence | high |
Classification note: The urgent community response team's handwritten medication information was transcribed into a homecare agency's eMAR without sodium valproate and without a cross-agency check.
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 | Not assessed in this dataset |
| Registered response sources | None registered for this row |
| Non-exclusive mechanism codes | PROV, LOOP, INT, HF |
Qualification recorded in the dataset: Primary report verified
“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
Medication handover and transcription controls required action
Requested action
Care organisations to act
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Handwritten MAR and electronic MAR |
| Digital function | Medication handover |
| Failure mode | Sodium valproate was omitted when handwritten medication information was transcribed into eMAR |
| Human-factors issue | Parallel representations obscured omission |
| Workflow issue | No cross-agency cross-check closed the handover |
| Information issue | Medication missing from receiving eMAR |
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.