Paul Price
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-126 · 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-PAUL-PRICE |
| Registered primary source | SRC-126 |
| Report date | 2018-09-19 |
| Coroner area | Birmingham and Solihull |
| Clinical setting | Community mental-health care |
| Care transition | GP, mental-health service and out-of-hours communication |
| Primary workflow group | Messaging, tasking and follow-up |
| Primary browsing context | Mental health care |
| Predominant information boundary | Between care settings |
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, Primary care, Patient or home |
| Information or work-item origin | Multiple settings or services |
| Origin care context(s) | Community care, Patient or public |
| Expected action destination | Multiple settings or services |
| Destination care context(s) | Primary care, Community care |
| 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 primary report identifies two pathways: a delayed mental-health assessment letter to the GP and a concern call to the mental-health team that was not recorded or returned during an outage. These have different 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 | Not assessed in this dataset |
| Registered response sources | None registered for this row |
| Non-exclusive mechanism codes | LOOP, GOV, INT, RES |
Qualification recorded in the dataset: The inquest returned an open conclusion; the report identifies interoperability and resilience concerns without finding that the digital mechanisms 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
Incompatible records and fragile fallback communication created a continuing risk
Requested action
Birmingham and Solihull Mental Health NHS Foundation Trust to act
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Incompatible GP and mental-health systems, fax and post |
| Digital function | Referral messaging and callback workflow |
| Failure mode | Incompatible systems forced referral information through fax and post, while an outage and lost callback left the communication incomplete |
| Human-factors issue | Manual channels and uncertain system availability obscured whether information had been received or actioned |
| Workflow issue | No resilient closed loop preserved ownership and escalation through outage and callback failure |
| Information issue | Referral and callback state was fragmented across incompatible systems and manual channels |
Downstream Defence trace
Canonical candidate requirements that cite this report: REQ-012. 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.
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