Kiefer Fraser-Phillips
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-185 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2026-0216 |
| Registered primary source | SRC-185 |
| Report date | 2026-04-14 |
| Coroner area | Birmingham and Solihull |
| Clinical setting | Mental-health inpatient care |
| Care transition | Therapeutic observation to contemporaneous ward record |
| Primary workflow group | Triage, observations and decision support |
| 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: Observations arose and were used on one inpatient mental-health ward; the failure occurred when creating the contemporaneous electronic record.
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; qualified extraction |
| Response evidence status | Response evidence noted |
| Registered response sources | SRC-227 |
| Non-exclusive mechanism codes | GOV, HF, PROV, RES |
Qualification recorded in the dataset: The death was recorded as sudden unexplained death in schizophrenia; the report presents observation-recording resilience as a future risk rather than a causal finding. The Judiciary page says 2026-04-14 while the embedded PFD is signed 2026-04-15.
“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
Connectivity failure created a risk that observations would not be recorded accurately and effectively
Requested action
Birmingham and Solihull Mental Health NHS Foundation Trust to address recording resilience and physical-health care planning
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Wireless electronic observation device |
| Digital function | Bedside observation recording |
| Failure mode | The device lost Wi-Fi and observations could not be entered until staff returned to the ward office |
| Human-factors issue | A mobile workflow depended on coverage unavailable at the point of care |
| Workflow issue | No resilient contemporaneous recording path existed during connectivity loss |
| Information issue | Observation timing and content could be recorded later rather than at the point of care |
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.