Jonathan Thornton
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-066 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2026-0200 |
| Registered primary source | SRC-066 |
| Report date | 2026-04-08 |
| Coroner area | Nottingham and Nottinghamshire |
| Clinical setting | Prison and forensic mental healthcare |
| Care transition | Community forensic team to prison healthcare and operational prison staff |
| Primary workflow group | Risk, care planning and safeguarding |
| Primary browsing context | Secure and custodial care |
| Predominant information boundary | Across health and non-health sectors |
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 mental-health care, Prison, custody or secure healthcare, Police, local authority or other non-health agency |
| Information or work-item origin | Multiple settings or services |
| Origin care context(s) | Community care, Secure or custodial healthcare |
| Expected action destination | Multiple settings or services |
| Destination care context(s) | Secure or custodial healthcare, Non-health agency |
| Directional pathway | Multiple settings or services → Multiple settings or services |
| Care-setting span | Multiple care settings |
| Sector boundary | Health and non-health sectors |
| Failure point | Multiple points |
| Classification confidence | high |
Classification note: Community forensic risk information and a prison-healthcare monitoring plan needed to reach prison healthcare and operational officers. The absent formal handover, broad operational alert categories, cross-system visibility limits and incomplete communication of the monitoring plan created material failures at multiple points across health and custodial operations.
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 | No official response located |
| Registered response sources | None registered for this row |
| Non-exclusive mechanism codes | LOOP, GOV, VIS, HF, INT, ALERT |
Qualification recorded in the dataset: Relevant record was the assailant's, not Jonathan's. Report identifies future-death risk but does not expressly find the information-system failures caused the fatal assault; no official response was located
“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
Lack of formal information sharing and insufficiently particular, visible cross-role alerts created a risk of future death
Requested action
Ministry of Justice, HMP Nottingham and two healthcare NHS foundation trusts to act
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | NOMIS/DPS alerts and absent formal handover mechanism |
| Digital function | Risk alerts, handover and monitoring tasking |
| Failure mode | NOMIS/DPS used broad preset violence categories, healthcare staff could not view its alerts, and no formal CFT-to-prison-healthcare handover system existed |
| Human-factors issue | Broad alerts did not convey the target or nature of risk; staff did not know they had been tasked to watch for deterioration |
| Workflow issue | A watch-and-wait plan was not communicated to all healthcare staff or to operational staff expected to observe behaviour |
| Information issue | Complex psychological history, triggers and the risk-management plan were unavailable or not understood across teams |
Downstream Defence trace
Canonical candidate requirements that cite this report: REQ-013. These links are analytical translations and do not make the requirement a coronial recommendation or a validated Defence control.
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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