Paul Harries
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-184 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2026-0242 |
| Registered primary source | SRC-184 |
| Report date | 2026-04-20 |
| Coroner area | West Sussex, Brighton and Hove |
| Clinical setting | Primary care, vascular surgery and emergency care |
| Care transition | GP referral and emergency imaging to vascular follow-up |
| Primary workflow group | Referral, handover and transfer |
| Primary browsing context | Cross-setting and multi-agency 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 | Primary care, Secondary acute or outpatient care, Laboratory, radiology or diagnostic service |
| Information or work-item origin | Multiple settings or services |
| Origin care context(s) | Primary care, Secondary care, Diagnostic service |
| Expected action destination | Multiple settings or services |
| Destination care context(s) | Primary care, Secondary care |
| Directional pathway | Multiple settings or services → Multiple settings or services |
| Care-setting span | Multiple care settings |
| Sector boundary | Health services only |
| Failure point | Multiple points |
| Classification confidence | high |
Classification note: Urgent referral and incidental-result information moved in both directions between primary care, vascular services and emergency imaging; failures occurred at more than one boundary.
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-226 |
| Non-exclusive mechanism codes | LOOP, GOV, VIS, HF, INT, PROV |
Qualification recorded in the dataset: The report identifies missed surveillance and delayed specialist review among wider clinical events; it makes no positive causal finding about the IT interfaces.
“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 GP-consultant-Careflow chain and incomplete IT integration continued to risk delayed review and lost findings
Requested action
University Hospitals Sussex NHS Foundation Trust to complete and assure corrective work on referral integration and incidental-finding communication
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Three partly integrated referral systems including Careflow |
| Digital function | Referral urgency, booking and incidental-finding communication |
| Failure mode | Manual coding could change GP urgency, three systems were not fully joined and significant incidental findings were not consistently reported to the GP |
| Human-factors issue | Users had to translate priority manually across systems and infer why a referral was recategorised |
| Workflow issue | No closed loop preserved the originating urgency or reliably returned recategorisation reasons and incidental findings |
| Information issue | Outstanding surveillance, changed urgency and clinically significant imaging findings were fragmented across services |
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.