Edward Muwanga
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-067 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2026-0235 |
| Registered primary source | SRC-067 |
| Report date | 2026-04-24 |
| Coroner area | Inner West London |
| Clinical setting | Community mental health, ambulance, NHS 111, police and supported living |
| Care transition | Community mental-health team to supported living, police, ambulance and NHS 111 |
| Primary workflow group | Risk, care planning and safeguarding |
| Primary browsing context | Cross-setting and multi-agency 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, Social care, care home or supported living, Police, local authority or other non-health agency, Ambulance, NHS 111 or urgent response |
| Information or work-item origin | Multiple settings or services |
| Origin care context(s) | Community care, Non-health agency |
| Expected action destination | Multiple settings or services |
| Destination care context(s) | Social care, Non-health agency, Ambulance or urgent response |
| Directional pathway | Multiple settings or services → Multiple settings or services |
| Care-setting span | Multiple care settings |
| Sector boundary | Health, social care and other non-health sectors |
| Failure point | Multiple points |
| Classification confidence | high |
Classification note: Risk, crisis and legal-status information arose across mental-health and police activity and was required by supported-living, police, ambulance and NHS 111 decision-makers; both transfer and destination access failed.
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-089, SRC-090, SRC-091, SRC-092, SRC-093, SRC-094 |
| Non-exclusive mechanism codes | INT, VIS, ALERT, LOOP, HF, GOV |
Qualification recorded in the dataset: Digital fragmentation was not found causal; specified LAS/NHS 111 communication shortcomings were stated not to affect the outcome. Later systems and planned improvements are response evidence
“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
Fragmented systems created a risk that practitioners would make decisions on incomplete information
Requested action
NHS England, OneLondon Board, London Ambulance Service, SLaM, College of Policing and Metropolitan Police to act
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Multiple agency EPRs and shared-care platforms |
| Digital function | Mental-health risk, crisis-plan and legal-status access |
| Failure mode | Important risk information was distributed across multiple platforms; the section 135 warrant was not communicated and the NHS 111 doctor did not access all available notes |
| Human-factors issue | Clinicians with little prior knowledge faced multiple screens and processes in which safety information was embedded or hard to find |
| Workflow issue | No reliable cross-agency workflow transferred the warrant, current risk state and crisis information to decision-makers |
| Information issue | More complete risk information existed but was not consistently visible or communicated |
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.