Kenneth Cully
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-181 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2026-0248 |
| Registered primary source | SRC-181 |
| Report date | 2026-04-30 |
| Coroner area | East Riding of Yorkshire and City of Kingston upon Hull |
| Clinical setting | Primary care and ambulance telephone triage |
| Care transition | Medication plan to repeat prescribing; 999 call to ambulance disposition |
| Primary workflow group | Triage, observations and decision support |
| Primary browsing context | Acute and emergency care |
| Predominant information boundary | Patient-to-service channel |
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 | Patient or home, Primary care, Ambulance, NHS 111 or urgent response |
| Information or work-item origin | Multiple settings or services |
| Origin care context(s) | Patient or public, Primary care |
| Expected action destination | Multiple settings or services |
| Destination care context(s) | Primary care, Ambulance or urgent response |
| 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: The report combines a primary-care prescribing strand with a patient-to-ambulance triage strand; failures occurred in separate origins and destinations.
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-222 |
| Non-exclusive mechanism codes | LOOP, GOV, HF, ALERT, PROV |
Qualification recorded in the dataset: The anticoagulant probably affected clotting and the triage gap created prospective risk, but the coroner could not determine whether a faster ambulance would have prevented death and did not isolate either digital mechanism as causal
“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 missing NHS Pathways question could produce incorrect categorisation and delay treatment of a catastrophic bleed
Requested action
NHS Pathways to address the triage-question gap
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | GP repeat-prescribing system, MPDS and NHS Pathways |
| Digital function | Repeat-prescription state and remote triage categorisation |
| Failure mode | The intended anticoagulant stop was entered as repeat medication and NHS Pathways lacked a question distinguishing controlled from uncontrolled bleeding |
| Human-factors issue | Call handlers depended on scripted questions and clinicians had repeated opportunities to recognise the continuing prescription |
| Workflow issue | No reliable reconciliation stopped the medicine as intended, while the triage workflow could not encode whether bleeding was controlled |
| Information issue | Treatment duration and the severity-defining bleed state were not represented reliably in the active workflows |
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.