Margaret Spencer
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-109 · 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-MARGARET-SPENCER |
| Registered primary source | SRC-109 |
| Report date | 2018-03-29 |
| Coroner area | Black Country |
| Clinical setting | Hospital outpatient care |
| Care transition | Diagnostic follow-up during system migration |
| Primary workflow group | Screening and longitudinal surveillance |
| Primary browsing context | Acute and emergency 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 | Secondary acute or outpatient care |
| Information or work-item origin | Secondary acute or outpatient care |
| Origin care context(s) | Secondary care |
| Expected action destination | Secondary acute or outpatient care |
| Destination care context(s) | Secondary care |
| Directional pathway | Secondary acute or outpatient care → Secondary acute or outpatient care |
| Care-setting span | One care setting |
| Sector boundary | Health services only |
| Failure point | Originating service |
| Classification confidence | high |
Classification note: An outpatient follow-up work item was prematurely closed during migration within the hospital service, so the electronic follow-up state was incorrect before later surveillance action was due.
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, RES, HF, GOV |
Qualification recorded in the dataset: The report described IT and administrative failures as contributing to a death also associated with neglect; it does not support attributing the outcome to Lorenzo alone
“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
System migration and administrative failures allowed required follow-up to be lost
Requested action
Walsall Healthcare NHS Trust to act
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Lorenzo patient administration system |
| Digital function | Follow-up list migration and tracking |
| Failure mode | Follow-up was prematurely closed during the Lorenzo migration and the patient was lost from surveillance |
| Human-factors issue | Migration, unfamiliar workflows and training limitations made follow-up state difficult to interpret |
| Workflow issue | No assured reconciliation identified prematurely closed or omitted follow-up work |
| Information issue | The electronic follow-up state no longer represented the outstanding clinical action |
Downstream Defence trace
Canonical candidate requirements that cite this report: REQ-010. 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.