Theresa Lydon
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-048 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2026-0244 |
| Registered primary source | SRC-048 |
| Report date | 2026-04-21 |
| Coroner area | Newcastle upon Tyne and North Tyneside |
| Clinical setting | Primary and hospital care |
| Care transition | GP and neighbouring hospital Trusts |
| Primary workflow group | Record access and continuity |
| 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 | Secondary acute or outpatient care, Primary care |
| Information or work-item origin | Secondary acute or outpatient care |
| Origin care context(s) | Secondary care |
| Expected action destination | Multiple settings or services |
| Destination care context(s) | Primary care, Secondary care |
| Directional pathway | Secondary acute or outpatient care → 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: Hospital information needed action by a GP and by clinicians in a neighbouring Trust; both the scanned treatment-plan letter and cross-Trust records failed at transfer.
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 | LOOP, GOV, VIS, HF, INT |
Qualification recorded in the dataset: Combines paper-electronic ingestion and interoperability
“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
National correspondence clarity and prompt cross-Trust access required action
Requested action
National and local recipients to act
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Scanned correspondence and separate hospital records |
| Digital function | Treatment plan/record access |
| Failure mode | Actions were obscured in non-standard scanned correspondence and neighbouring Trust records arrived after death |
| Human-factors issue | Administrator cues and variable formats shaped what GP saw |
| Workflow issue | Treatment action and cross-Trust retrieval lacked reliable ownership/timeliness |
| Information issue | Action hidden; external records delayed |
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.
Return to all included reports · Open the corpus profile · Review assurance and uncertainty · Open the case–mechanism/evidence map