Marian Grant
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-125 · 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-MARIAN-GRANT |
| Registered primary source | SRC-125 |
| Report date | 2018-09-15 |
| Coroner area | Oxfordshire |
| Clinical setting | Acute hospital care |
| Care transition | Admission assessment to VTE prophylaxis |
| Primary workflow group | Medication and prescribing |
| 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 | Receiving or action service |
| Classification confidence | high |
Classification note: The VTE assessment and warning existed within the hospital EPR, but its timing and presentation did not produce prophylaxis action at the admission decision 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 | ALERT, VIS, HF, LOOP |
Qualification recorded in the dataset: The report and investigation described the EPR difficulty as a root cause in an avoidable sequence; it does not establish that interface design alone caused the death
“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
Technical difficulty with the EPR warning contributed to missed VTE prophylaxis
Requested action
Oxford University Hospitals NHS Foundation Trust to act
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Electronic patient record VTE assessment |
| Digital function | VTE warning and prophylaxis decision support |
| Failure mode | The VTE warning was encountered at an ineffective point in the EPR workflow and repeated record access did not result in a recalled, actioned alert |
| Human-factors issue | The warning timing and presentation did not fit the clinical task, so passive exposure did not create reliable understanding |
| Workflow issue | No owned task or escalation ensured completion of prophylaxis after the warning |
| Information issue | The EPR held the assessment state but did not make the unresolved risk persistently actionable |
Downstream Defence trace
Canonical candidate requirements that cite this report: REQ-009. 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.