Ethan Hanson
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-071 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2026-0229 |
| Registered primary source | SRC-071 |
| Report date | 2026-03-30 |
| Coroner area | Warwickshire |
| Clinical setting | Primary care/emergency paediatrics |
| Care transition | GP to emergency department |
| Primary workflow group | Triage, observations and decision support |
| Primary browsing context | Maternity and paediatric care |
| Predominant information boundary | Hybrid paper and digital record |
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 | Primary care, Acute paediatric care |
| Information or work-item origin | Primary care |
| Origin care context(s) | Primary care |
| Expected action destination | Acute paediatric care |
| Destination care context(s) | Secondary care |
| Directional pathway | Primary care → Acute paediatric care |
| Care-setting span | Multiple care settings |
| Sector boundary | Health services only |
| Failure point | Multiple points |
| Classification confidence | high |
Classification note: GP findings failed to accompany self-presentation, while observation validation and completeness also failed inside emergency paediatrics; transfer and destination failures were both material.
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, ALERT, INT, HF, GOV |
Qualification recorded in the dataset: Medical-misadventure conclusion; evidence linked the correct temperature to escalation and likely diagnosis after senior review, but the report did not isolate absence of an EPR as the cause of death
“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
Computerised mandatory-field safeguards, guideline-aligned pathways, structured neurodivergence support and reliable GP information transfer were absent
Requested action
Hospital and national bodies to act
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Paper observation/referral process and developing hospital EPR |
| Digital function | Observation validation, triage and referral transfer |
| Failure mode | A temperature/oxygen-saturation transposition was not blocked, required observations and pain scores were incomplete, and GP findings did not accompany self-presentation |
| Human-factors issue | Manual documentation, neurodivergent communication needs and route-dependent assumptions shaped assessment |
| Workflow issue | No mandatory completion or validation before pathway selection/discharge; self-presentation bypassed a written clinical handover |
| Information issue | Abnormal observations and GP diagnostic concern were absent from the receiving assessment |
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.