Joseph Cooper
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-183 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2026-0237 |
| Registered primary source | SRC-183 |
| Report date | 2026-04-30 |
| Coroner area | Greater Manchester South |
| Clinical setting | Community mental-health and drug-and-alcohol services |
| Care transition | Mental-health record to substance-misuse treatment |
| Primary workflow group | Record access and continuity |
| Primary browsing context | Mental health 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 mental-health care |
| Information or work-item origin | Multiple settings or services |
| Origin care context(s) | Community care |
| Expected action destination | Multiple settings or services |
| Destination care context(s) | Community care |
| Directional pathway | Multiple settings or services → Multiple settings or services |
| Care-setting span | Multiple care settings |
| Sector boundary | Health services only |
| Failure point | Transfer or interface |
| Classification confidence | high |
Classification note: Two distinct community services under one Trust required access to one another's records; several providers share the same controlled setting code.
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-224, SRC-225 |
| Non-exclusive mechanism codes | GOV, VIS, INT |
Qualification recorded in the dataset: The conclusion referred to unmet mental-health needs and intoxication; the report frames record fragmentation as a future-death concern and does not isolate it as the cause
“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
The absence of complete and unified digital health records created risk for patients with co-occurring conditions
Requested action
Secretary of State for Health and Social Care to address co-occurring-condition care, online alcohol access and the absence of unified digital NHS records
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Separate NHS mental-health and drug-and-alcohol records |
| Digital function | Cross-service clinical-record access |
| Failure mode | Drug-and-alcohol professionals could not access mental-health records despite both services operating under the same NHS foundation trust |
| Human-factors issue | Clinicians treating co-occurring conditions had to work from a partial view of the patient's needs |
| Workflow issue | No unified or viewer-access workflow joined the two services' treatment information |
| Information issue | Mental-health information was unavailable to the drug-and-alcohol team |
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.