Caliel Smith-Kwami
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-106 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| Project report ID (official PFD reference not shown) | UNREF-2018-CALIEL-SMITH-KWAMI |
| Registered primary source | SRC-106 |
| Report date | 2018-01-22 |
| Coroner area | London (East) |
| Clinical setting | Neonatal hospital care |
| Care transition | Laboratory result to paediatric follow-up |
| Primary workflow group | Diagnostic results and investigations |
| Primary browsing context | Maternity and paediatric care |
| Predominant information boundary | Hybrid paper and digital record |
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 | Laboratory, radiology or diagnostic service, Acute paediatric care |
| Information or work-item origin | Laboratory, radiology or diagnostic service |
| Origin care context(s) | Diagnostic service |
| Expected action destination | Acute paediatric care |
| Destination care context(s) | Secondary care |
| Directional pathway | Laboratory, radiology or diagnostic service → Acute paediatric care |
| Care-setting span | Multiple care settings |
| Sector boundary | Health services only |
| Failure point | Transfer or interface |
| Classification confidence | high |
Classification note: The abnormal newborn-screening result arose in the laboratory and required paediatric follow-up; electronic availability without active notification and loss of the paper notice made the transfer boundary the predominant failure point.
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, ALERT, VIS, HF, GOV |
Qualification recorded in the dataset: The report connected the missed abnormal result and referral to delayed diagnosis; the electronic record was one component of a hybrid notification failure and is not isolated as the sole 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 hybrid result-notification process allowed an abnormal newborn-screening result to remain unactioned
Requested action
Barts Health NHS Trust to act
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Electronic health record and paper laboratory notification |
| Digital function | Newborn-screening result filing and notification |
| Failure mode | An abnormal result was entered in the electronic record without a reliable active notification, while the paper notification was lost |
| Human-factors issue | Passive electronic availability and ordinary filing did not give the time-critical result sufficient salience |
| Workflow issue | No closed-loop acknowledgement or escalation ensured that the abnormal result was reviewed and acted on |
| Information issue | The critical result existed electronically but was not delivered to an accountable clinician |
Downstream Defence trace
Canonical candidate requirements that cite this report: REQ-004. These links are analytical translations and do not make the requirement a coronial recommendation or a validated Defence control.
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.