Amy Chapman
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-182 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2026-0247 |
| Registered primary source | SRC-182 |
| Report date | 2026-04-27 |
| Coroner area | West Sussex, Brighton and Hove |
| Clinical setting | Informal community-based mental-health placement |
| Care transition | Risk and leave plan to nursing decision and observation |
| Primary workflow group | Risk, care planning and safeguarding |
| Primary browsing context | Mental health care |
| Predominant information boundary | Within a care setting |
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 | Community mental-health care |
| Origin care context(s) | Community care |
| Expected action destination | Community mental-health care |
| Destination care context(s) | Community care |
| Directional pathway | Community mental-health care → Community mental-health care |
| Care-setting span | One care setting |
| Sector boundary | Health services only |
| Failure point | Multiple points |
| Classification confidence | medium |
Classification note: The PFD expressly describes the Haven Unit as an informal community-based placement at Millview Hospital; the physical configuration is not further resolved, so it is not coded as an inpatient unit.
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; qualified extraction |
| Response evidence status | Response evidence noted |
| Registered response sources | SRC-223 |
| Non-exclusive mechanism codes | LOOP, GOV, VIS, HF, ALERT, PROV |
Qualification recorded in the dataset: The coroner found gross failures of basic care around record checking and leave decisions; the report raises the alert and audit design as ongoing concerns but does not isolate SystmOne as the cause. The source describes the Haven Unit as an informal community-based placement.
“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
Record checking, recording practice, SystmOne alert capability and incomplete audit left leave risk inadequately controlled
Requested action
Sussex Partnership NHS Foundation Trust to address the identified care-planning, recording, alert and audit concerns
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | SystmOne case notes and observation record |
| Digital function | Leave-restriction alerting, decision recording and observation audit |
| Failure mode | Nurses did not read the notes or record leave decisions, alert capability for restrictions was uncertain and observations were not audited against case notes |
| Human-factors issue | Staff unfamiliar with the patient made significant leave decisions in an informal working culture without consulting the record |
| Workflow issue | No dependable pre-leave record check, decision documentation or reconciliation of observations against authorised leave existed |
| Information issue | Family-accompaniment restrictions, reasons for decisions and the relationship between leave and observations were absent from the view used |
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.