Source register
This is the canonical provenance register. Each persistent SRC- identifier names one bounded source record; IDs are never renumbered or reused. A source's presence does not make every statement in it a coronial finding or validate any downstream analysis.
Use the register with the source-type and authority guide:
- Primary PFD reports and legislation are authoritative for what the coroner or law states within scope.
- Official recipient responses are respondent accounts. They can clarify, disagree or report proposed action, but do not establish implementation or effectiveness.
- Review data and supplied material support discovery, coding and audit; they cannot create new report facts.
- Method, literature, programme and technical sources support their stated context only.
Browse included report records · Browse official response evidence · Review counter-positions · Review assurance and uncertainty
The table intentionally remains one stable-ID sequence so existing deep links continue to resolve. Use browser search for a source ID, report name or source role; use the source-type guide for grouped authority boundaries.
| ID | Source | Date / retrieved | Scope and type | Reliability notes |
|---|---|---|---|---|
| SRC-001 | Stephen Rhodes PFD, ref 2026-0083 | Report 2026-02-06; retrieved 2026-07-14 | Primary judiciary publication; report text and PDF | High authority for the coroner's findings; not proof of general prevalence |
| SRC-002 | Rachelle Ross PFD, ref 2023-0067 | Report 2023-02-17; retrieved 2026-07-14 | Primary judiciary publication | High authority for stated concern; product names retain source spelling variants |
| SRC-003 | Alexander Braund PFD, ref 2022-0407 | Report 2022-12-20; retrieved 2026-07-14 | Primary judiciary publication | High authority for concern; distinguishes audit evidence from printed summary |
| SRC-004 | Morris Reddington PFD, ref 2021-0312 | Report 2021-05-21; retrieved 2026-07-14 | Primary judiciary report | High authority for the ambulance-to-hospital handover concern |
| SRC-005 | Project sponsor brief and DMICP architecture clarification | Received 2026-07-14; clarified 2026-07-15 | Discovery lead / supplied synthesis | Sponsor confirms that the live DMICP application is EMIS PCS/DPCS, MCN means MOD Core Network, and the service is centrally hosted inside Defence/MCN infrastructure and accessed through MCN/MODNet clients—not practice-local servers. Sponsor also clarifies that e-RS is a separate HSCN/Spine web application used in a native browser, not a DMICP integration; EPS, GP Connect, NHS App, Summary Care Record and the Scottish, Welsh and Northern Irish national platforms are unavailable to Defence. The sponsor cannot presently confirm DMICP's DCB0129/DCB0160 or Defence-equivalent regime, named Clinical Safety Officer, Hazard Log or Clinical Safety Case; their status is unknown, not evidence of absence or non-conformity. This is current operational context, not independent evidence; exact application version/adaptations, service path, interface catalogue and authoritative architecture remain to be verified. |
| SRC-006 | Zensical: create your site and build command | Retrieved 2026-07-14 | Official renderer documentation | Authority for renderer commands and configuration approach only |
| SRC-007 | ICMM Abu Dhabi abstract submission | Retrieved 2026-07-14 | Official event page: themes, timetable and submission overview | Newest page shows 2026-08-03 deadline; conflicts with SRC-009 |
| SRC-008 | ICMM 2026 abstract guidelines | Retrieved 2026-07-14 | Official guideline PDF | Authority for word/title/keyword limits, originality, author limit and oral duration |
| SRC-009 | ICMM World Congresses | Retrieved 2026-07-14 | Official parent ICMM page | Still shows 2026-07-14 deadline; unresolved conflict with event page |
| SRC-010 | Coroners and Justice Act 2009, Schedule 5 paragraph 7 | Retrieved 2026-07-14 | Primary legislation | Authority for the statutory reporting duty |
| SRC-011 | Coroners (Investigations) Regulations 2013, Part 7 | Retrieved 2026-07-14 | Primary legislation | Regulations 28–29 govern report and response procedure, including the normal 56-day response period |
| SRC-012 | ICMM project brief supplied by project owner | Received 2026-07-14 | Sponsor brief, preserved under research/briefs/ |
Research direction and hypotheses; not independent evidence for case facts or current submission rules |
| SRC-013 | Included-case dataset, screening log and 2018 publication-cohort manifest | Search and dataset updated 2026-07-22 | Local analytical dataset, retained candidate decisions and archive/extraction audit trail | Every included row has a stable source ID and official Judiciary link; the 2018 manifest completely records archive enumeration and extraction but only 36 cohort rows have retained contextual dispositions. The 2025–2026 publication-date update screen is reproducibly bounded, while the wider targeted pass remains non-exhaustive and requires a pre-submission rerun. |
| SRC-014 | Stephen Stringer PFD, ref 2024-0555 | Report 2024-10-15; retrieved 2026-07-14 | Primary judiciary report | Identifies digital enquiry routing, record-incorporation and clinical-visibility concerns; incident supplier is not named |
| SRC-015 | Morris Reddington joint response | Retrieved 2026-07-14 | Official recipient response | Supports the technical account and proposed FHIR remedy; not itself a coronial finding |
| SRC-016 | TPP response to Ross | Retrieved 2026-07-14 | Official recipient response | Says SystmOne already alerted when a smear was due and that national non-responder status was not supplied into the EPR; respondent account, not a coronial finding |
| SRC-017 | TPP response to Braund | Retrieved 2026-07-14 | Official recipient response | Clarifies that the live audit trail retained prior text and metadata; the exported summary did not expose it |
| SRC-018 | Quarry Bank Medical Centre response to Rhodes | Retrieved 2026-07-14 | Official recipient response | Provides the ICE/EMIS routing explanation; keep distinct from the coroner's stated concern |
| SRC-019 | Eric Thompson PFD, ref 2024-0323 | Report 2024-06-14; retrieved 2026-07-14 | Primary judiciary report | Strong evidence for the distinction between electronic availability and accountable delivery |
| SRC-020 | Stephen Cassidy PFD, ref 2023-0337 | Report 2023-09-19; retrieved 2026-07-14 | Primary judiciary report | Strong cross-boundary allergy/record-access example |
| SRC-021 | Samuel Jordan PFD, ref 2024-0056 | Report 2024-02-02; retrieved 2026-07-14 | Primary judiciary report | Direct evidence that administrative registration selected an incomplete recent record source |
| SRC-022 | Audrey King PFD, ref 2023-0312 | Report 2023-08-22; retrieved 2026-07-14 | Primary judiciary report | Strong paper–electronic medication-workflow example |
| SRC-023 | Derby and Derbyshire ICB response to Stringer | Retrieved 2026-07-14 | Official recipient response | Discusses integration choices and local action; does not establish the incident supplier |
| SRC-024 | Zhang and Richards: Lessons from web scraping PFD reports | Published 2023; retrieved 2026-07-14 | Peer-reviewed methods/commentary paper | Supports reproducible large-scale PFD collection; does not validate this review's digital case coding |
| SRC-025 | Hodgson et al: emergency-department PFD thematic analysis | Published 2024; retrieved 2026-07-14 | Peer-reviewed thematic analysis | Demonstrates a clinical-setting-specific PFD analysis |
| SRC-026 | Qin et al: mental-health PFD network and thematic analysis | Published 2026; retrieved 2026-07-14 | Peer-reviewed network/thematic analysis | Demonstrates contemporary large-corpus analysis and overlapping systems concerns |
| SRC-027 | Torab-Miandoab et al: military EHR systematic review | Published 2025; retrieved 2026-07-14 | Peer-reviewed systematic review | Supports military relevance of interoperability, infrastructure, privacy/security and deployment-context challenges |
| SRC-028 | Welsh Government PFD statement | Published 2024-03-19; retrieved 2026-07-14 | Official ministerial statement | Reports a rise in all PFDs and integrated-record concerns; cannot establish a digital-PFD trend |
| SRC-029 | EHR interoperability patient-safety incident analysis | Published 2018; retrieved 2026-07-14 | Peer-reviewed incident-report analysis | External triangulation for pharmacy, laboratory and radiology interface hazards |
| SRC-030 | JBI Manual for Evidence Synthesis 2024 | Published 2024; retrieved 2026-07-15 | Official evidence-synthesis manual | Supports separation of question, inclusion, search, extraction, mapped results, discussion and implications; this project does not claim full JBI scoping-review conduct |
| SRC-031 | PRISMA 2020 expanded checklist | Published 2021; retrieved 2026-07-15 | Official reporting checklist | Supports explicit reporting of selection, data items, synthesis, limitations and certainty methods; use does not make the current pass systematic |
| SRC-032 | NHS England: Thinking thematically | Published 2022; retrieved 2026-07-15 | Official patient-safety thematic-review guidance | Supports transparent inductive/deductive framing, triangulation and theme tables/maps |
| SRC-033 | Judiciary PFD FAQ 2026 | Published 2026; retrieved 2026-07-15 | Official Judiciary procedural and search guidance | Authority for searchable fields, consistent full-text webpage publication from 2023 and the limit that coroners do not assess response adequacy or enforce action |
| SRC-034 | GOV.UK: Designing good government services | Updated 2024; retrieved 2026-07-15 | Official service-design guidance | Technical information-architecture context: organise around user needs and avoid exposing internal structures |
| SRC-035 | Zensical navigation, tags and search | Retrieved 2026-07-15 | Official renderer documentation | Authority for supported navigation, search and tag behaviour only; tag listing/faceted browsing limitations remain current-version dependent |
| SRC-036 | 3ie evidence-gap-map guidance | Retrieved 2026-07-15 | Official evidence-mapping guidance and examples | Supports matrix/filter interaction patterns; this targeted corpus is labelled an evidence map, not an evidence-gap map |
| SRC-037 | Cochrane Handbook chapter 22 | Handbook 2024; retrieved 2026-07-15 | Official living-review methodology | Supports making surveillance and update frequency explicit; the current project is not labelled a living systematic review |
| SRC-038 | Emma Sanders PFD, ref 2024-0646 | Report 2024-11-26; retrieved 2026-07-14 | Primary judiciary report | High authority for the coroner’s stated report-specific concern; does not establish prevalence, product-wide performance or causal contribution beyond the source |
| SRC-039 | Lily Jahany PFD, ref 2024-0273 | Report 2024-05-17; retrieved 2026-07-14 | Primary judiciary report | High authority for the coroner’s stated report-specific concern; does not establish prevalence, product-wide performance or causal contribution beyond the source |
| SRC-040 | Colin Greenway PFD, ref 2023-0252 | Report 2023-07-18; retrieved 2026-07-14 | Primary judiciary report | High authority for the coroner’s stated report-specific concern; does not establish prevalence, product-wide performance or causal contribution beyond the source |
| SRC-041 | Paula Doreen Hughes PFD, ref 2025-0511 | Report 2025-10-14; retrieved 2026-07-14 | Primary judiciary report | High authority for the coroner’s stated report-specific concern; does not establish prevalence, product-wide performance or causal contribution beyond the source |
| SRC-042 | Oliver Billings PFD, ref 2024-0656 | Report 2024-11-28; retrieved 2026-07-14 | Primary judiciary report | High authority for the coroner’s stated report-specific concern; does not establish prevalence, product-wide performance or causal contribution beyond the source |
| SRC-043 | Valerie Gibson PFD, ref 2025-0630 | Report 2025-12-17; retrieved 2026-07-14 | Primary judiciary report | High authority for the coroner’s stated report-specific concern; does not establish prevalence, product-wide performance or causal contribution beyond the source |
| SRC-044 | Michael Nye PFD, ref 2024-0082 | Report 2024-02-13; retrieved 2026-07-14 | Primary judiciary report | High authority for the coroner’s stated report-specific concern; does not establish prevalence, product-wide performance or causal contribution beyond the source |
| SRC-045 | John Spencer PFD, ref 2025-0232 | Report 2025-05-19; retrieved 2026-07-14 | Primary judiciary report | High authority for the coroner’s stated report-specific concern; does not establish prevalence, product-wide performance or causal contribution beyond the source |
| SRC-046 | Hannah Booth PFD, ref 2025-0615 | Report 2025-12-09; retrieved 2026-07-14 | Primary judiciary report | High authority for the coroner’s stated report-specific concern; does not establish prevalence, product-wide performance or causal contribution beyond the source |
| SRC-047 | Darren Turner PFD, ref 2025-0144 | Report 2025-03-17; retrieved 2026-07-14 | Primary judiciary report | High authority for the coroner’s stated report-specific concern; does not establish prevalence, product-wide performance or causal contribution beyond the source |
| SRC-048 | Theresa Lydon PFD, ref 2026-0244 | Report 2026-04-21; retrieved 2026-07-14 | Primary judiciary report | High authority for the coroner’s stated report-specific concern; does not establish prevalence, product-wide performance or causal contribution beyond the source |
| SRC-049 | Darran Busby PFD, ref 2022-0011 | Report 2022-01-13; retrieved 2026-07-14 | Primary judiciary report | High authority for the coroner’s stated report-specific concern; does not establish prevalence, product-wide performance or causal contribution beyond the source |
| SRC-050 | Sebastian Daniels PFD, ref 2023-0346 | Report 2023-09-22; retrieved 2026-07-14 | Primary judiciary report | High authority for the coroner’s stated report-specific concern; does not establish prevalence, product-wide performance or causal contribution beyond the source |
| SRC-051 | Jennifer Trigger PFD, ref 2024-0116 | Report 2024-03-01; retrieved 2026-07-14 | Primary judiciary report | High authority for the coroner’s stated report-specific concern; does not establish prevalence, product-wide performance or causal contribution beyond the source |
| SRC-052 | Michael Amesbury PFD, ref 2023-0259 | Report 2023-07-19; retrieved 2026-07-14 | Primary judiciary report | High authority for the coroner’s stated report-specific concern; does not establish prevalence, product-wide performance or causal contribution beyond the source |
| SRC-053 | John Fisher PFD, ref 2026-0166 | Report 2026-03-19; retrieved 2026-07-14 | Primary judiciary report | High authority for the coroner’s stated report-specific concern; does not establish prevalence, product-wide performance or causal contribution beyond the source |
| SRC-054 | Donald Compton PFD, ref 2022-0090 | Report 2022-03-20; retrieved 2026-07-14 | Primary judiciary report | High authority for the coroner’s stated report-specific concern; does not establish prevalence, product-wide performance or causal contribution beyond the source |
| SRC-055 | Chloe Burgess PFD, ref 2025-0121 | Report 2025-03-04; retrieved 2026-07-14 | Primary judiciary report | High authority for the coroner’s stated report-specific concern; does not establish prevalence, product-wide performance or causal contribution beyond the source |
| SRC-056 | Avery Hall PFD, ref 2026-0048 | Report 2026-02-02; retrieved 2026-07-14 | Primary judiciary report | High authority for the coroner’s stated report-specific concern; does not establish prevalence, product-wide performance or causal contribution beyond the source |
| SRC-057 | John James PFD, ref 2023-0242 | Report 2023-07-11; retrieved 2026-07-14 | Primary judiciary report | High authority for the coroner’s stated report-specific concern; does not establish prevalence, product-wide performance or causal contribution beyond the source |
| SRC-058 | Jack Farrington PFD, ref 2023-0436 | Report 2023-09-14; retrieved 2026-07-14 | Primary judiciary report | High authority for the coroner’s stated report-specific concern; does not establish prevalence, product-wide performance or causal contribution beyond the source |
| SRC-059 | Francis Barnes PFD, ref 2023-0417 | Report 2023-10-27; retrieved 2026-07-14 | Primary judiciary report | High authority for the coroner’s stated report-specific concern; does not establish prevalence, product-wide performance or causal contribution beyond the source |
| SRC-060 | Christopher Collinson PFD, ref 2021-0361 | Report 2021-10-26; retrieved 2026-07-14 | Primary judiciary report | High authority for the coroner’s stated report-specific concern; does not establish prevalence, product-wide performance or causal contribution beyond the source |
| SRC-061 | Hugo Carlos PFD, ref 2023-0038 | Report 2023-02-01; retrieved 2026-07-14 | Primary judiciary report | High authority for the coroner’s stated report-specific concern; does not establish prevalence, product-wide performance or causal contribution beyond the source |
| SRC-062 | John Singleton PFD, ref 2024-0126 | Report 2023-11-16; retrieved 2026-07-14 | Primary judiciary report | High authority for the coroner’s stated report-specific concern; does not establish prevalence, product-wide performance or causal contribution beyond the source |
| SRC-063 | Jason Bayley PFD, ref 2023-0392 | Report 2023-10-17; retrieved 2026-07-14 | Primary judiciary report | High authority for the coroner’s stated report-specific concern; does not establish prevalence, product-wide performance or causal contribution beyond the source |
| SRC-064 | Ania Sohail PFD, ref 2023-0046 | Report 2023-02-07; retrieved 2026-07-14 | Primary judiciary report | High authority for the coroner’s stated report-specific concern; does not establish prevalence, product-wide performance or causal contribution beyond the source |
| SRC-065 | Akhona Moyo PFD, ref 2026-0045 | Report 2026-01-28; retrieved 2026-07-14 | Primary judiciary report | High authority for the coroner’s stated report-specific concern; does not establish prevalence, product-wide performance or causal contribution beyond the source |
| SRC-066 | Jonathan Thornton PFD, ref 2026-0200 | Report 2026-04-08; retrieved 2026-07-14 | Primary judiciary report | High authority for the coroner’s stated report-specific concern; does not establish prevalence, product-wide performance or causal contribution beyond the source |
| SRC-067 | Edward Muwanga PFD, ref 2026-0235 | Report 2026-04-24; retrieved 2026-07-14 | Primary judiciary report | High authority for the coroner’s stated report-specific concern; does not establish prevalence, product-wide performance or causal contribution beyond the source |
| SRC-068 | Elton Deutekom PFD, ref 2024-0660 | Report 2024-12-02; retrieved 2026-07-14 | Primary judiciary report | High authority for the coroner’s stated report-specific concern; does not establish prevalence, product-wide performance or causal contribution beyond the source |
| SRC-069 | Ethel Reed PFD, ref 2024-0076 | Report 2024-02-08; retrieved 2026-07-14 | Primary judiciary report | High authority for the coroner’s stated report-specific concern; does not establish prevalence, product-wide performance or causal contribution beyond the source |
| SRC-070 | Theo Tuikubulau PFD, ref 2026-0006 | Report 2026-01-06; retrieved 2026-07-14 | Primary judiciary report | High authority for the coroner’s stated report-specific concern; does not establish prevalence, product-wide performance or causal contribution beyond the source |
| SRC-071 | Ethan Hanson PFD, ref 2026-0229 | Report 2026-03-30; retrieved 2026-07-14 | Primary judiciary report | High authority for the coroner’s stated report-specific concern; does not establish prevalence, product-wide performance or causal contribution beyond the source |
| SRC-072 | Tracy McCarthy PFD, ref 2024-0280 | Report 2024-05-21; retrieved 2026-07-14 | Primary judiciary report | High authority for the coroner’s stated report-specific concern; does not establish prevalence, product-wide performance or causal contribution beyond the source |
| SRC-073 | Bernard Compton PFD, ref 2024-0304 | Report 2024-06-05; retrieved 2026-07-14 | Primary judiciary report | High authority for the coroner’s stated report-specific concern; does not establish prevalence, product-wide performance or causal contribution beyond the source |
| SRC-074 | Anthony Binfield; David Richards; Rolandas Karbauskas PFD, ref 2025-0079 | Report 2025-02-07; retrieved 2026-07-14 | Primary judiciary report | High authority for the coroner’s stated report-specific concern; does not establish prevalence, product-wide performance or causal contribution beyond the source |
| SRC-075 | Tammy Milward PFD, ref 2025-0027 | Report 2025-01-15; retrieved 2026-07-14 | Primary judiciary report | High authority for the coroner’s stated report-specific concern; does not establish prevalence, product-wide performance or causal contribution beyond the source |
| SRC-076 | EMIS response to Ross | Retrieved 2026-07-15 | Official recipient response | Says EMIS displayed a generic cervical-smear due/outstanding alert and considered the system compliant; it does not itself establish that national non-responder status was supplied |
| SRC-077 | NHS England response to Ross | Retrieved 2026-07-15 | Official recipient response | Addresses points directed to NHS Digital; describes generic overdue alerts and separate national non-responder cards/worklists, not a coronial finding |
| SRC-078 | Department of Health and Social Care response to Ross | Retrieved 2026-07-15 | Official recipient response | Describes planned Cervical Screening Management System access to non-responder lists; later policy context, not evidence that vendor changes were implemented |
| SRC-079 | NHS England and NHS Improvement response to Reddington | Retrieved 2026-07-15 | Official recipient response | Responds to the separate thrombectomy concern in the bundled PFD publication; does not support the ePRF/FHIR account |
| SRC-080 | Riverview Surgery response to Avery Hall | Retrieved 2026-07-15 | Official recipient response | Incident-specific practice account and proposed prescribing controls, including an EMIS enquiry; actions and plans are respondent evidence only |
| SRC-081 | Royal College of General Practitioners response to Avery Hall | Retrieved 2026-07-15 | Official recipient response | General prescribing and GP-system context; notes uncertainty about repeat-prescription alerts across suppliers and is not incident-specific product evidence |
| SRC-082 | Oxford University Hospitals NHS Foundation Trust response to Francis Barnes | Retrieved 2026-07-15 | Official recipient response | Retains telephone referral for emergencies and proposes a Microsoft 365 documentation form; a respondent plan, not proof of implementation or a coronial finding |
| SRC-083 | University Hospitals Birmingham NHS Foundation Trust response to Christopher Collinson | Retrieved 2026-07-15 | Official recipient response | Says PICS replaced the hybrid allocation process and explains why the Trust rejected a generic confirmation alert; respondent safety argument only |
| SRC-084 | NHS England response to John Singleton | Retrieved 2026-07-15 | Official recipient response | Prefers actionable HJIS reports to a passive record flag and describes proposed follow-up work; does not establish implementation |
| SRC-085 | St Andrew’s Healthcare response to Jason Bayley | Retrieved 2026-07-15 | Official recipient response | Gives the respondent’s minimal-or-trivial contribution position and proposed reconciliation/technical controls; neither is a coronial finding |
| SRC-086 | NHS England response to Akhona Moyo | Retrieved 2026-07-15 | Official recipient response | States Nervecentre went live at Northampton General Hospital on 27 June 2025 and describes national record-sharing programmes; later state, not the 2022 incident system |
| SRC-087 | Department of Health and Social Care response to Akhona Moyo | Retrieved 2026-07-15 | Official recipient response | Describes the planned Single Patient Record; later policy context, not evidence of incident-state access or implementation |
| SRC-088 | University Hospitals of Northamptonshire NHS Group response to Akhona Moyo | Retrieved 2026-07-15 | Official recipient response | Distinguishes the November 2022 access position from later NCR, GP Connect and Nervecentre integration; respondent account with stated continuing limitations |
| SRC-089 | OneLondon Board response to Edward Muwanga | Retrieved 2026-07-15 | Official recipient response | Describes later systems, known visibility limits and planned work; respondent evidence, not proof that changes prevent recurrence |
| SRC-090 | South London and Maudsley NHS Foundation Trust response to Edward Muwanga | Retrieved 2026-07-15 | Official recipient response | Describes information available at the time and later LCR, eMHA and crisis-planning work; retains limits on visibility and cross-system interpretation |
| SRC-091 | NHS England response to Edward Muwanga | Retrieved 2026-07-15 | Official recipient response | National and local record-sharing context; does not establish that every relevant item was visible or used in the incident workflow |
| SRC-092 | College of Policing response to Edward Muwanga | Retrieved 2026-07-15 | Official recipient response | Addresses policing guidance and training, not the digital-health-record characterisation in the included row |
| SRC-093 | Metropolitan Police response to Edward Muwanga | Retrieved 2026-07-15 | Official recipient response | Describes training and police intelligence-system changes for section 135 warrants; not evidence about health-record interoperability |
| SRC-094 | London Ambulance Service NHS Trust response to Edward Muwanga | Retrieved 2026-07-15 | Official recipient response | Describes current fragmentation, later integrations, prompts and planned work; respondent account, not implementation assurance |
| SRC-095 | Chelsea and Westminster Hospital NHS Foundation Trust response to Elton Deutekom | Retrieved 2026-07-15 | Official recipient response | Says the handwritten note was accurately transcribed under policy before disposal and denies concealment; explicitly the Trust’s position, not an independently established fact |
| SRC-096 | NHS England response to Elton Deutekom | Retrieved 2026-07-15 | Official recipient response | Addresses national maternity and medical-examiner matters; does not support the Trust’s transcription or concealment position |
| SRC-097 | Humber Health Partnership response to Ethel Reed | Retrieved 2026-07-15 | Official recipient response | Confirms the Immediate Discharge Summary author-attribution issue and proposed process changes; does not itself state that the underlying audit trail was complete |
| SRC-098 | Care Quality Commission response to Ethel Reed | Retrieved 2026-07-15 | Official recipient response | Describes oversight and reported mitigation of the Lorenzo issue; does not establish a complete audit trail |
| SRC-099 | NHS England response to Ethel Reed | Retrieved 2026-07-15 | Official recipient response | Says a full system audit trail existed while the distributed/finalised IDS did not display amendment authorship; respondent clarification, not supplier evidence |
| SRC-100 | NHS England response to Theo Tuikubulau, 2 March 2026 | Retrieved 2026-07-15 | Official recipient response | Concludes no system change was required and that both systems converge for the stated high-acuity presentation; NHS England’s review conclusion, not a coronial finding |
| SRC-101 | NHS England clarification response to Theo Tuikubulau, 16 June 2026 | Retrieved 2026-07-15 | Official recipient response | Says both systems generate category 1 when the presentation is appropriately triaged; does not independently validate how the incident call was handled |
| SRC-102 | GP Partners at the Tredegar Practice response to Tracy McCarthy | Retrieved 2026-07-15 | Official recipient response | Identifies EMIS and proposes a coded Risk Management and Care Planning Register; a local plan, not proof of implementation or product performance |
| SRC-103 | NHS England response to Bernard Compton | Retrieved 2026-07-15 | Official recipient response | Says NHS Pathways is non-diagnostic and reports that NWAS considered category 3 appropriate for the symptoms supplied; this is not a direct NWAS response |
| SRC-104 | Surrey Heartlands ICB response attachment for Tammy Milward | Retrieved 2026-07-15 | Official Judiciary-published response attachment | Describes Surrey Care Record and email mitigations; the ICB was not named as a report recipient and the attachment is not a substitute for a missing SABP-labelled response |
| SRC-105 | Esher Green Surgery response to Tammy Milward | Retrieved 2026-07-15 | Official recipient response | Proposes timely verbal communication followed by email pending integration; respondent plan, not implementation evidence |
| SRC-106 | Caliel Smith-Kwami PFD | Report 2018-01-22; retrieved 2026-07-15 | Primary Judiciary report; official page shows no PFD reference | Authoritative for the report-specific result-notification concern; UNREF-2018-CALIEL-SMITH-KWAMI is a project ID, not an official reference |
| SRC-107 | Pauline Pryor PFD, ref 2018-0009 | Report 2018-01-12; retrieved 2026-07-15 | Primary Judiciary report | Authoritative for the report-specific monitoring, reminder and follow-up concerns; does not isolate a digital causal contribution |
| SRC-108 | David Buttriss PFD, ref 2018-0010 | Report 2018-01-12; retrieved 2026-07-15 | Primary Judiciary report | Authoritative for the report-specific cross-service record-access concern; does not establish that record fragmentation caused the death |
| SRC-109 | Margaret Spencer PFD | Report 2018-03-29; retrieved 2026-07-15 | Primary Judiciary report; official page shows no PFD reference | Authoritative for the Lorenzo migration and follow-up concern; UNREF-2018-MARGARET-SPENCER is a project ID, not an official reference |
| SRC-110 | Patricia Heslop PFD, ref 2018-0102 | Report 2018-04-12; retrieved 2026-07-15 | Primary Judiciary report | Authoritative for the report-specific disconnected-record and ownership concern; the report qualified the delay as non-causal |
| SRC-111 | Adrian Jennings PFD, ref 2018-0111 | Report 2018-04-19; retrieved 2026-07-15 | Primary Judiciary report | Authoritative for the report-specific separate-system and Lorenzo-field concern; the digital mechanism is one part of a wider communication failure |
| SRC-112 | Greg Hutchins PFD, ref 2018-0129 | Report 2018-09-12; retrieved 2026-07-15 | Primary Judiciary report | Authoritative for the report-specific RiO documentation and record-sharing concern; no separate digital causal finding is inferred |
| SRC-113 | Joanne Richardson PFD, ref 2018-0134 | Report 2018-05-08; retrieved 2026-07-15 | Primary Judiciary report | Authoritative for the report-specific partial RiO access and referral-record concern; records future risk rather than a digital causal finding |
| SRC-114 | Stephen Tidey PFD, ref 2018-0140 | Report 2018-05-08; retrieved 2026-07-15 | Primary Judiciary report | Authoritative for the report-specific multi-agency risk-information and referral-ownership concern; the digital mechanism cannot be isolated from the wider pathway |
| SRC-115 | Grahame Searby PFD, ref 2018-0162 | Report 2018-05-23; retrieved 2026-07-15 | Primary Judiciary report | Authoritative for the report-specific SystmOne/EMIS access concern; the outcome of improved access is uncertain |
| SRC-116 | Joan Lunt PFD, ref 2018-0164 | Report 2018-05-29; retrieved 2026-07-15 | Primary Judiciary report | Authoritative for the report-specific shared-identity and electronic-record provenance concern; the death was from natural causes |
| SRC-117 | Michalla Sweeting PFD, ref 2018-0165 | Report 2018-05-21; retrieved 2026-07-15 | Primary Judiciary report | Authoritative for the report-specific SystmOne visibility and action concern; the jury's neglect finding combines multiple factors |
| SRC-118 | Darren Carrington PFD, ref 2018-0181 | Report 2018-06-15; retrieved 2026-07-15 | Primary Judiciary report | Authoritative for the report-specific prescribing-alert and distributed-supply concern; the digital contribution is not isolated from prescribing and patient behaviour |
| SRC-119 | John Hazlewood PFD, ref 2018-0189 | Report 2018-06-21; retrieved 2026-07-15 | Primary Judiciary report | Authoritative for the report-specific remote record-access and documentation concern; no product-wide conclusion is supported |
| SRC-120 | Jacob Sulaiman PFD, ref 2018-0252 | Report 2018-07-06; retrieved 2026-07-15 | Primary Judiciary report | Authoritative for the report-specific shared telecare database and emergency-information concern; the report states only that fuller information may have affected assessment |
| SRC-121 | Michael Drewell PFD, ref 2018-0259 | Report 2018-08-30; retrieved 2026-07-15 | Primary Judiciary report | Authoritative for the report-specific handwritten/electronic medication-record boundary; causation was expressly uncertain |
| SRC-122 | Steven Welch PFD, ref 2018-0267 | Report 2018-08-07; retrieved 2026-07-15 | Primary Judiciary report | Authoritative for the report-specific cross-border radiology-transfer concern; the coroner said the errors were unlikely to have caused the death |
| SRC-123 | Cuthbert Hingert PFD, page ref 2018-0280 | Report 2018-08-01; retrieved 2026-07-15 | Primary Judiciary report | Page shows 2018-0280 while the report filename shows 2018-0279; authoritative for the JAC medication-database concern, with reference discrepancy retained for recheck |
| SRC-124 | Brian Bicat PFD, ref 2018-0277 | Report 2018-05-29; retrieved 2026-07-15 | Primary Judiciary report | Authoritative for the report-specific inconsistency in paraffin-emollient fire-risk prescribing warnings; does not establish a digital causal contribution |
| SRC-125 | Marian Grant PFD | Report 2018-09-15; retrieved 2026-07-15 | Primary Judiciary report; official page shows no PFD reference | Authoritative for the report-specific EPR VTE-warning concern; UNREF-2018-MARIAN-GRANT is a project ID, not an official reference |
| SRC-126 | Paul Price PFD | Report 2018-09-19; retrieved 2026-07-15 | Primary Judiciary report; official page shows no PFD reference | Authoritative for the report-specific incompatible-system, fax/post and callback-resilience concern; UNREF-2018-PAUL-PRICE is a project ID, not an official reference |
| SRC-127 | Redacted PFD, ref 2018-0405 | Report 2018-12-21; retrieved 2026-07-15 | Primary Judiciary report; page published/migrated in 2024 | Authoritative for the report-specific overwrite, validation and record-interpretability concern; the coroner said the two reported issues could not be said to have caused or contributed to this death |
| SRC-128 | Karl Willis PFD, ref 2018-0256 | Report 2018-08-24; retrieved 2026-07-15 | Primary Judiciary report | Authoritative for the online self-certification and GP-notification safeguard concerns; the online supply formed part of the fatal medication circumstances |
| SRC-129 | Mavis Reeves PFD, ref 2018-0035 | Report 2018-02-06; retrieved 2026-07-15 | Primary Judiciary report | Authoritative for the analogue/digital telecare architecture and emergency-access concern; bounded health-IT inclusion, not an EHR case, and no causal digital finding is inferred |
| SRC-130 | DCB0129: Clinical Risk Management in the Manufacture of Health IT Systems, specification v4.2 | Issued 2018-05-02; retrieved 2026-07-15 | Official NHS information-standard specification | Primary authority for manufacturer clinical-risk-management requirements; current 2018 release is under national review, and this source is not a DMICP manufacturer safety case |
| SRC-131 | DCB0160: Clinical Risk Management in the Deployment and Use of Health IT Systems, specification v3.2 | Issued 2018-05-02; retrieved 2026-07-15 | Official NHS information-standard specification | Primary authority for deploying/using organisation requirements across deployment, use, maintenance and decommissioning; does not itself show Defence applicability or conformity |
| SRC-132 | DCB0160 implementation guidance v4.2 | Issued 2018-05-02; retrieved 2026-07-15 | Official NHS implementation guidance | Supports end-to-end process, interface, messaging, data-transfer, human-interaction, infrastructure, migration and local-configuration analysis; guidance must be read with the specification |
| SRC-133 | NHS England: Digital clinical safety assurance | Version 1.2; updated 2025-03-04; retrieved 2026-07-15 | Official NHS clinical-safety guidance | Concise authority for DCB0129/DCB0160 responsibility, CSO and core artefact expectations; explanatory guidance, not a substitute for the standards or deployment evidence |
| SRC-134 | NHS England: national review of DCB0129 and DCB0160 — supporting information | Published 2026-06-29; retrieved 2026-07-15 | Official NHS standards-review publication | Confirms the 2018 versions remain current while review is under way and records gaps identified by consultation work; it is not a replacement standard and its legal-status wording should not be simplified |
| SRC-135 | NHS England: Patient Safety Incident Response Framework | Published 2022-08-16; updated 2025-09-23; retrieved 2026-07-15 | Official NHS patient-safety framework | Authority for patient-safety incident definition, proportionate response and system-based learning; its remit is distinct from coronial investigation and DCB clinical-risk management |
| SRC-136 | MOD: UK service personnel medical discharges background quality report 2022 | Published 2022; retrieved 2026-07-15 | Official MOD statistics quality report | High authority for DMICP's integrated primary Health Record and central-warehouse baseline; not current hosting, interface, product-version or CORTISONE implementation evidence |
| SRC-137 | UK Parliament/MOD: Defence Medical Services — ICT, written answer 174007 | Answered 2018-10-09; retrieved 2026-07-15 | Official parliamentary answer | Authority for historical 2007 rollout, MODNet-terminal, fixed/deployed and replacement context at the date answered; user/device figures are not current service sizing |
| SRC-138 | UK Parliament/MOD: Armed Forces — Health Services, written answer 47398 | Answered 2025-04-29; retrieved 2026-07-15 | Official parliamentary answer | Supports CORTISONE stabilisation/replacement status and home-nation interoperability as a programme driver; not an interface catalogue or delivered-state assurance |
| SRC-139 | CGI: Defence Medical Services DMICP case study | Historical case study; PDF republished 2022; retrieved 2026-07-15 | Vendor implementation case study | CGI describes a centrally hosted service in its secure Wales data centre, EMIS PCS adapted for the military population, dedicated-portal access and a deployed variant that synchronised on connectivity; moderate historical context only, not current official architecture or product evidence |
| SRC-140 | CQC: Defence Medical Services medical-centre findings, 2022/23 | Published 2023-07-06; retrieved 2026-07-15 | Official CQC inspection synthesis under the DMSR-invited programme | Supports dated findings on record quality, interfaces among DMICP variants, diagnostic/discharge/record-transfer workarounds and unavailable records; CQC does not have its usual statutory/enforcement powers for DMS, and this is not a DCB assessment or current prevalence estimate |
| SRC-141 | CQC: Defence Medical Services medical-centre findings, 2024/25 | Published 2025-07-17; retrieved 2026-07-15 | Official CQC inspection synthesis under the DMSR-invited programme | The programme-wide information-systems section records incomplete/inaccurate records and variable Read coding at some services. Separately, across four facilities unable to ensure effective care, listed common concerns included staff inability to use DMICP for searches, recall assurance and monitoring; the synthesis does not give the per-concern facility count, isolate software/configuration/training/governance causation or constitute a DCB assessment |
| SRC-142 | Sibling-project DMICP evidence audit | Completed 2026-07-15; archived at research/audits/dmicp-sibling-audit-2026-07-15.md |
Project-internal source-routing and claim-boundary audit | Confirms source trails and evidence gaps but is not independent authority; no patient-, practice- or facility-level data are reproduced, and the underlying primary sources are cited wherever available |
| SRC-143 | Armed Forces Covenant and Veterans Annual Report 2025 | Published 2025; retrieved 2026-07-15 | Official UK government annual report | Supports planned CORTISONE module go-lives and a March 2028 DMICP-retirement target as at publication; programme-plan evidence, not proof of delivery or clinical-safety approval |
| SRC-144 | MOD Electronic Health Records and Medicine Management System contract award | Awarded 2025-12-08; published 2026-01-14; retrieved 2026-07-15 | Official Contracts Finder award notice | Names TPP and scope including four-nation registration, primary care, referrals, tasking, prescribing, intermediate care and medicines; procurement evidence, not live configuration, interface conformance or safety-case approval |
| SRC-145 | MOD: UK armed forces mental health 2025/26 annual report | Published 2026-07-02; retrieved 2026-07-15 | Official MOD statistics publication | Calls DMICP the MOD electronic medical record, uses it as a 2025/26 data source and identifies it as a live system whose late entries or amendments can fall outside a timed extract; strong evidence of current use, not architecture, interface or clinical-safety assurance |
| SRC-146 | MOD contract notice: Object Code and Source Code for the Underlying Platform of DMICP — DPCS | Contract award decision 2019-06-12; retrieved 2026-07-15 | Official public-procurement notice | Identifies the then underlying DMICP platform as EMIS's legacy DPCS and EMIS as its original developer and sole source; authoritative for the 2019 procurement, not proof that the same version or components remain deployed in 2026 |
| SRC-147 | MOD Future Service Delivery Contract, Schedule 1 definitions and parent Contracts Finder notice | Awarded 2019-12-18; contract start 2020-06-01; parent notice published 2021-02-17; retrieved 2026-07-15 | Official personnel/HR/JPA-service public-procurement schedule | Defines MCN as the MoD Core Network and MODNet as end-user-accessed devices and networked systems replacing DII for that contract; dated terminology evidence only, not a DMICP contract or evidence of DMICP's present network/hosting path |
| SRC-148 | NHS England: Commissioner Assignment Method 2025/26 guidance | 2025/26 guidance; retrieved 2026-07-15 | Official NHS England operational guidance | States that DMS primary-care registration is held in DMICP and that DMICP is integrated with the Spine Patient Demographic Service, including security-motivated civilianisation of demographic data; one named interface, not a complete service inventory |
| SRC-149 | UK Parliament/MOD: Armed Forces — Medical Records, written answer 111862 | Answered 2017-11-13; retrieved 2026-07-15 | Official parliamentary answer | Records an interface between DMICP and an NHS messaging service for electronic delivery of pathology reports at the date answered; historical selective-integration evidence, not current end-to-end closure assurance |
| SRC-150 | CQC: Redford Medical Centre inspection report | Published 2025-12-16; retrieved 2026-07-15 | Official CQC site-inspection report under the DMSR-invited programme | Documents site-specific SCI Store access, manual referral tracking, paper/email pathology handling, transcription risk and incomplete visibility of result review in DMICP, alongside local mitigations; not representative of all DMS facilities or product-wide behaviour |
| SRC-151 | CQC: Sennelager Medical Centre inspection report | Published 2026-06-16; retrieved 2026-07-15 | Official CQC site-inspection report under the DMSR-invited programme | Records a site-level NHS/German-provider/DMICP connectivity risk, paper-record and translation workflow, limited e-RS access, DMICP tasking and separate referral registers with mitigations; not representative of all DMS facilities or product-wide behaviour |
| SRC-152 | MOD: New digital medical records to speed up Armed Forces recruitment | Published 2026-01-23; retrieved 2026-07-15 | Official MOD programme announcement | States that present NHS–DMS record transfer relies on paperwork and announces a TPP successor intended to improve transfer; programme communication, not proof that all existing interfaces are absent or that the replacement is live |
| SRC-153 | UK Parliament/MOD: Armed Forces — Medical Records, written answer HL14105 | Answered 2026-02-12; retrieved 2026-07-15 | Official parliamentary answer | Names SystmOne and says rollout is scheduled to begin in 2027; forward programme status, not completion, deployed configuration or safety acceptance |
| SRC-154 | MOD CORTISONE Case Officer Assurance Support contract award | Awarded 2025-11-28; published 2026-01-05; retrieved 2026-07-15 | Official Contracts Finder award notice | Describes assurance support across CORTISONE, Live Service and DMICP from December 2025 to November 2026; procurement evidence of assurance activity, not a clinical-safety case or evidence that a control is effective |
| SRC-155 | CGI: UK Ministry of Defence selects CGI to provide integrated electronic health-record service | Published 2015-12-03; retrieved 2026-07-15 | Vendor press release | Corroborates a dated EMIS PCS basis and secure CGI UK hosting for the INTERMOLAR/DMICP continuation service; historical supplier account and capacity statement, not current topology or independent assurance |
| SRC-156 | CQC: Brawdy Medical Centre inspection report | Published 2026-01-05; inspection 2025-11-09; retrieved 2026-07-15 | Official CQC site-inspection report under the DMSR-invited programme | States that the Defence system was not linked with Welsh NHS online services, routine FIT home-test kits had been unavailable to the practice and a local electronic-form/email workaround improved access; also records age-related DMICP slow response, regular outages and limited newer-technology compatibility as widely affecting DPHC. It records local controls but is not a DCB assessment, causal analysis or quantified prevalence estimate |
| SRC-157 | CQC: Northern Ireland Regional Rehabilitation Unit inspection report | Published 2023-04-04; retrieved 2026-07-15 | Official CQC site-inspection report under the DMSR-invited programme | Records use of a separate Defence Patient Tracking System that did not link with DMICP, a separate sent-referral folder and DMICP documentation of non-attendance at this Northern Ireland rehabilitation unit; setting- and date-specific workflow evidence, not a national-service inventory |
| SRC-158 | CQC: Tidworth Medical Centre inspection report | Published 2021-11-04; retrieved 2026-07-15 | Official CQC site-inspection report under the DMSR-invited programme | Records an England workflow spanning a DMICP referrals inbox, NHS e-Referral Service, SharePoint registers and DMICP task acknowledgements, plus paper fallback during outage; historical site evidence with recorded controls and gaps, not current product-wide behaviour |
| SRC-159 | BMJ Military Health: instructions for authors | Page updated 2026-06-30; retrieved 2026-07-15 | Official journal submission guidance | Authority for the current Analysis article structure and limits: 2,000 main-text words, 250-word unstructured abstract, six combined tables/figures and 30 references, plus the three-part key-message box; requirements must be rechecked in ScholarOne before submission |
| SRC-160 | BMJ Author Hub: formatting your paper | Retrieved 2026-07-15 | Official publisher formatting guidance | Authority for Word submission, manuscript order, in-text table placement, Vancouver numbering and reference-list formatting; journal-specific instructions take precedence |
| SRC-161 | BMJ Author Hub: AI use | Retrieved 2026-07-15 | Official publisher policy | Requires transparent disclosure of the technology, purpose and use, a contributor statement and fuller methods description when AI supports research; AI cannot be an author and human authors remain accountable |
| SRC-162 | Sittig and Singh: sociotechnical model for health IT | Published 2010; retrieved 2026-07-15 | Peer-reviewed conceptual paper | Supports analysis of interacting technical and non-technical dimensions; it is a model, not evidence that every dimension contributed to a particular Defence event |
| SRC-163 | Meeks et al: EHR-related patient-safety concerns | Published 2014; retrieved 2026-07-15 | Peer-reviewed analysis of 100 closed US Veterans Health Administration investigations | Supports the recurrence and multi-dimensionality of display, transmission, upgrade and hidden-dependency concerns in one mature US system; not a UK or DMICP incidence estimate |
| SRC-164 | Singh and Sittig: Health IT Safety Framework | Published 2016; retrieved 2026-07-15 | Peer-reviewed conceptual framework | Supports combined measurement of unsafe technology, unsafe use and technology-enabled safety surveillance; does not itself validate a local control |
| SRC-165 | Li et al: EHR interoperability and safety systematic review | Published 2022; retrieved 2026-07-15 | Peer-reviewed systematic review | Supports probable benefits and heterogeneous evidence across high-income settings; uncertain effect estimates and varied definitions limit causal or Defence-specific inference |
| SRC-166 | Li et al: English NHS clinician interoperability survey | Published 2025; retrieved 2026-07-15 | Peer-reviewed cross-sectional survey | Supports clinicians' reported practical safety and efficiency consequences of limited external-record access; convenience/snowball sampling and perceptions do not estimate incident frequency |
| SRC-167 | Morris et al: Royal Navy cervical-screening coverage and digital surveillance | Online First 2025; final issue 2026; retrieved 2026-07-15 | Peer-reviewed BMJ Military Health case-study letter | Direct Defence context for limitations of digital screening surveillance at sea; the final citation is 2026;172(3):281–282, and the report should not be generalised to every cohort or current configuration |
| SRC-168 | O'Sullivan: EHR under-recording of osteoarthritis in the UK armed forces | Online First 2025; final issue 2026; retrieved 2026-07-15 | Peer-reviewed BMJ Military Health letter | Direct Defence context for the difference between coded EHR data and disease burden; the final citation is 2026;172(3):284, and no wider DMICP safety conclusion is inferred |
| SRC-169 | Reg 28 PFD Reference material.docx; SHA-256 d28e500e3bd5e06f248e36e65bbe105d56ac3ef682f41c124e96c7bd16f20083 |
Project-supplied 2026-07-22; rendered and reconciled 2026-07-22 | Supplied secondary synthesis and discovery artefact | Useful for search leads and analytical questions only. Its uncited framework, incomplete case linking, AI-discovery URL parameters and substantive case conflicts mean it cannot establish a coronial finding, current system fact, causal claim, Defence requirement or programme assurance conclusion; see the audit. |
| SRC-170 | Leicestershire Partnership NHS Trust response to John Hazlewood | Response 2018-08-13; retrieved 2026-07-22 | Official recipient response | Supports the Trust's account of remote clinical-system access and strengthened induction/audit controls by August 2018; it does not independently verify access coverage, use or outcomes |
| SRC-171 | University Hospitals of Leicester NHS Trust response to John Hazlewood | Response 2018-08-07; retrieved 2026-07-22 | Official recipient response | Supports UHL's account of mental-health training and escalation measures, not the Partnership Trust's remote-access remedy; it is not implementation assurance |
| SRC-172 | London Borough of Camden response to Jacob Sulaiman | Response 2018-10-03; retrieved 2026-07-22 | Official recipient response | Supports Camden's account of the fragmented Careline/Wellbeing setup and its planned platform, history checklist and safeguarding referral; plans do not prove delivery or effectiveness and this is not an ambulance-service response |
| SRC-173 | Walsall Healthcare NHS Trust response to Margaret Spencer | Response 2018-05-25; retrieved 2026-07-22 | Official recipient response | Supports the Trust's account of the Lorenzo access-plan closure, backlog and audit/training actions; it remains respondent investigation and action evidence, not independent assurance of Lorenzo or remediation |
| SRC-174 | Portsmouth Hospitals University NHS Trust response to Jack Farrington | Response 2024-01-08; retrieved 2026-07-22 | Official recipient response | Supports PHU's self-reported huddles, risk-flag/SOP work, partner EPR access and proposed electronic handover; several measures were planned or in development and effectiveness is unverified |
| SRC-175 | Solent NHS Trust response to Jack Farrington | Response 2023-12-18; retrieved 2026-07-22 | Official recipient response | Supports Solent's stated SystmOne handover/digitisation timetable and interim audit controls; the response reports delay, so completion and effectiveness are not inferred |
| SRC-176 | Coastal Homecare response to John Fisher | Response 2026-05-12; retrieved 2026-07-22 | Official recipient response | Supports the provider's self-reported medication photography, cross-checking, pharmacy liaison and GP Connect integration; adoption and effectiveness are unverified and the full CQC report was still pending |
| SRC-177 | Sussex Community NHS Foundation Trust response to John Fisher | Response 2026-05-11; retrieved 2026-07-22 | Official recipient response | Supports SCFT's internal rapid-review findings and claimed Plexus, pharmacy and reconciliation controls; scheduled items and operational effectiveness are not independently verified |
| SRC-178 | Old Mill Surgery response to Ethan Hanson | Response 2026-04-14; retrieved 2026-07-22 | Official recipient response | Supports the practice's statement that it added an EMIS referral protocol and induction material; it supplies no independent audit of consistent use or outcomes |
| SRC-179 | Royal College of General Practitioners response to Ethan Hanson | Response 2026-05-22; retrieved 2026-07-22 | Official recipient response | Supports RCGP's curriculum/context account and planned educational webinar; it is not evidence of local implementation, system interoperability or mandatory-field controls |
| SRC-180 | George Eliot Hospital NHS Trust response to Ethan Hanson | Response 2026-05-21; retrieved 2026-07-22 | Official recipient response | Supports GEH's stated paper mitigations, Integrated Care Record access, planned EPR controls and other actions; future milestones and performance remain respondent-reported and unverified |
| SRC-181 | Kenneth Cully PFD, ref 2026-0248 | Report 2026-04-30; retrieved 2026-07-22 | Primary Judiciary report | High authority for the coroner's stated report-specific concern; does not establish prevalence, current product-wide behaviour or causal contribution beyond the source |
| SRC-182 | Amy Chapman PFD, ref 2026-0247 | Report 2026-04-27; retrieved 2026-07-22 | Primary Judiciary report | High authority for the coroner's stated report-specific concern; does not establish prevalence, current product-wide behaviour or causal contribution beyond the source |
| SRC-183 | Joseph Cooper PFD, ref 2026-0237 | Report 2026-04-30; retrieved 2026-07-22 | Primary Judiciary report | High authority for the coroner's stated report-specific concern; does not establish prevalence, current product-wide behaviour or causal contribution beyond the source |
| SRC-184 | Paul Harries PFD, ref 2026-0242 | Report 2026-04-20; retrieved 2026-07-22 | Primary Judiciary report | High authority for the coroner's stated report-specific concern; does not establish prevalence, current product-wide behaviour or causal contribution beyond the source |
| SRC-185 | Kiefer Fraser-Phillips PFD, ref 2026-0216 | Page date 2026-04-14; embedded report signed 2026-04-15; retrieved 2026-07-22 | Primary Judiciary report | High authority for the coroner's stated report-specific concern; does not establish prevalence, current product-wide behaviour or causal contribution beyond the source. The dataset preserves the landing-page date and records the one-day discrepancy with the signed report. |
| SRC-186 | Hollie Loraine PFD, ref 2026-0193 | Report 2026-04-01; retrieved 2026-07-22 | Primary Judiciary report | High authority for the coroner's stated report-specific concern; does not establish prevalence, current product-wide behaviour or causal contribution beyond the source |
| SRC-187 | Delwyn Preece PFD, ref 2026-0165 | Report 2026-03-17; retrieved 2026-07-22 | Primary Judiciary report | High authority for the coroner's stated report-specific concern; does not establish prevalence, current product-wide behaviour or causal contribution beyond the source |
| SRC-188 | Darryl Johnson PFD, ref 2026-0152 | Report 2026-03-10; retrieved 2026-07-22 | Primary Judiciary report | High authority for the coroner's stated report-specific concern; does not establish prevalence, current product-wide behaviour or causal contribution beyond the source |
| SRC-189 | Roman Barr PFD, ref 2026-0148 | Report 2026-03-04; retrieved 2026-07-22 | Primary Judiciary report | High authority for the coroner's stated report-specific concern; does not establish prevalence, current product-wide behaviour or causal contribution beyond the source |
| SRC-190 | Ruairi Stewart PFD, ref 2026-0138 | Report 2026-03-10; retrieved 2026-07-22 | Primary Judiciary report | High authority for the coroner's stated report-specific concern; does not establish prevalence, current product-wide behaviour or causal contribution beyond the source |
| SRC-191 | Emma Turner PFD, ref 2026-0115 | Report 2026-02-25; retrieved 2026-07-22 | Primary Judiciary report | High authority for the coroner's stated report-specific concern; does not establish prevalence, current product-wide behaviour or causal contribution beyond the source |
| SRC-192 | Elise Sebastian PFD, ref 2026-0078 | Report 2026-02-08; retrieved 2026-07-22 | Primary Judiciary report | High authority for the coroner's stated report-specific concern; does not establish prevalence, current product-wide behaviour or causal contribution beyond the source |
| SRC-193 | Gareth Chumber-Kelly PFD, ref 2026-0073 | Report 2026-02-09; retrieved 2026-07-22 | Primary Judiciary report | High authority for the coroner's stated report-specific concern; does not establish prevalence, current product-wide behaviour or causal contribution beyond the source. The landing-page metadata says North London; the embedded signed report says Inner North London, which the dataset uses. |
| SRC-194 | Roger Smith PFD, ref 2026-0069 | Report 2026-02-06; retrieved 2026-07-22 | Primary Judiciary report | High authority for the coroner's stated report-specific concern; does not establish prevalence, current product-wide behaviour or causal contribution beyond the source |
| SRC-195 | Anthony Card PFD, ref 2026-0068 | Report 2025-11-07; retrieved 2026-07-22 | Primary Judiciary report | High authority for the coroner's stated report-specific concern; does not establish prevalence, current product-wide behaviour or causal contribution beyond the source |
| SRC-196 | Lyn Maher PFD, ref 2026-0053 | Report 2026-02-03; retrieved 2026-07-22 | Primary Judiciary report | High authority for the coroner's stated report-specific concern; does not establish prevalence, current product-wide behaviour or causal contribution beyond the source |
| SRC-197 | Nigel Feckey PFD, ref 2026-0047 | Report 2026-01-28; retrieved 2026-07-22 | Primary Judiciary report | High authority for the report text. Siloed systems and missed digital messages appear in the jury narrative/circumstances; the formal Regulation 28 concern and action relate only to offence-neutrality policy. |
| SRC-198 | Pippa Gillibrand PFD, ref 2026-0042 | Report 2026-01-27; retrieved 2026-07-22 | Primary Judiciary report | High authority for the coroner's stated report-specific concern; does not establish prevalence, current product-wide behaviour or causal contribution beyond the source |
| SRC-199 | Stuart Berry PFD, ref 2026-0015 | Report signed 2026-01-12; retrieved 2026-07-22 | Primary Judiciary report | High authority for the report text. The Judiciary page labels the report 2025-12-01, before the stated 2025-12-05 inquest conclusion; the dataset therefore uses the embedded signed date and retains the discrepancy. |
| SRC-200 | Robert Gracey PFD, ref 2026-0004 | Report 2026-01-06; retrieved 2026-07-22 | Primary Judiciary report | High authority for the coroner's stated report-specific concern; does not establish prevalence, current product-wide behaviour or causal contribution beyond the source |
| SRC-201 | Colin Brown PFD, ref 2025-0642 | Report 2025-12-23; retrieved 2026-07-22 | Primary Judiciary report | High authority for the coroner's stated report-specific concern; does not establish prevalence, current product-wide behaviour or causal contribution beyond the source |
| SRC-202 | Ethel Robertson PFD, ref 2025-0584 | Report 2025-11-17; retrieved 2026-07-22 | Primary Judiciary report | High authority for the coroner's stated report-specific concern; does not establish prevalence, current product-wide behaviour or causal contribution beyond the source |
| SRC-203 | Alan Mitchell PFD, ref 2025-0577 | Report 2025-11-10; retrieved 2026-07-22 | Primary Judiciary report | High authority for the coroner's stated report-specific concern; does not establish prevalence, current product-wide behaviour or causal contribution beyond the source |
| SRC-204 | Gloria Simon PFD, ref 2025-0554 | Report 2025-10-31; retrieved 2026-07-22 | Primary Judiciary report | High authority for the coroner's stated report-specific concern; does not establish prevalence, current product-wide behaviour or causal contribution beyond the source |
| SRC-205 | Melanie Walker PFD, ref 2025-0529 | Report 2025-10-17; retrieved 2026-07-22 | Primary Judiciary report | High authority for the coroner's stated report-specific concern; does not establish prevalence, current product-wide behaviour or causal contribution beyond the source |
| SRC-206 | Thompson Elliott PFD, ref 2025-0515 | Report 2025-10-14; retrieved 2026-07-22 | Primary Judiciary report | High authority for the coroner's stated report-specific concern; does not establish prevalence, current product-wide behaviour or causal contribution beyond the source |
| SRC-207 | Jillian Steedman PFD, ref 2025-0506 | Report 2025-10-10; retrieved 2026-07-22 | Primary Judiciary report | High authority for the coroner's stated report-specific concern; does not establish prevalence, current product-wide behaviour or causal contribution beyond the source |
| SRC-208 | Derek Crowther PFD, ref 2025-0500 | Report 2025-10-09; retrieved 2026-07-22 | Primary Judiciary report | High authority for the coroner's stated report-specific concern; does not establish prevalence, current product-wide behaviour or causal contribution beyond the source |
| SRC-209 | James Cochrane PFD, ref 2025-0454 | Report 2025-09-05; retrieved 2026-07-22 | Primary Judiciary report | High authority for the coroner's stated report-specific concern; does not establish prevalence, current product-wide behaviour or causal contribution beyond the source |
| SRC-210 | Venetia Pierce PFD, ref 2025-0427 | Report 2025-08-19; retrieved 2026-07-22 | Primary Judiciary report | High authority for the coroner's stated report-specific concern; does not establish prevalence, current product-wide behaviour or causal contribution beyond the source |
| SRC-211 | Jessica Smithson PFD, ref 2025-0415 | Report 2025-08-08; retrieved 2026-07-22 | Primary Judiciary report | High authority for the coroner's stated report-specific concern; does not establish prevalence, current product-wide behaviour or causal contribution beyond the source |
| SRC-212 | John Bell PFD, ref 2025-0410 | Report 2025-08-04; retrieved 2026-07-22 | Primary Judiciary report | High authority for the coroner's stated report-specific concern; does not establish prevalence, current product-wide behaviour or causal contribution beyond the source |
| SRC-213 | Lee Dryden PFD, ref 2025-0402 | Report 2023-08-02; retrieved 2026-07-22 | Primary Judiciary report | High authority for the coroner's stated report-specific concern; does not establish prevalence, current product-wide behaviour or causal contribution beyond the source; the 2023 report appears under a 2025 Judiciary reference |
| SRC-214 | Margaret McNaughton PFD, ref 2025-0397 | Report 2025-08-01; retrieved 2026-07-22 | Primary Judiciary report | High authority for the coroner's stated report-specific concern; does not establish prevalence, current product-wide behaviour or causal contribution beyond the source |
| SRC-215 | Myles Scriven PFD, ref 2025-0357 | Report 2025-07-11; retrieved 2026-07-22 | Primary Judiciary report | High authority for the coroner's stated report-specific concern; does not establish prevalence, current product-wide behaviour or causal contribution beyond the source; page metadata says 2025-07-11 while the embedded report is signed 2025-07-14 |
| SRC-216 | Miles Robinson PFD, ref 2025-0340 | Report 2025-07-08; retrieved 2026-07-22 | Primary Judiciary report | High authority for the coroner's stated report-specific concern; does not establish prevalence, current product-wide behaviour or causal contribution beyond the source |
| SRC-217 | Jason Clemens PFD, ref 2025-0336 | Report 2025-07-02; retrieved 2026-07-22 | Primary Judiciary report | High authority for the coroner's stated report-specific concern; does not establish prevalence, current product-wide behaviour or causal contribution beyond the source |
| SRC-218 | Thomas Mallinson PFD, ref 2025-0333 | Report 2025-06-30; retrieved 2026-07-22 | Primary Judiciary report | High authority for the coroner's stated report-specific concern; does not establish prevalence, current product-wide behaviour or causal contribution beyond the source |
| SRC-219 | Amy Cross PFD, ref 2025-0531 | Report 2025-10-22; retrieved 2026-07-22 | Primary Judiciary report | High authority for the coroner's stated report-specific concern; does not establish prevalence, current product-wide behaviour or causal contribution beyond the source; page metadata says 2025-10-22 while the embedded report is signed 2025-10-20 |
| SRC-220 | Stephen Neville PFD, ref 2025-0556 | Report 2025-10-24; retrieved 2026-07-22 | Primary Judiciary report | High authority for the coroner's stated report-specific concern; does not establish prevalence, current product-wide behaviour or causal contribution beyond the source |
| SRC-221 | Alan Peet PFD, ref 2025-0609 | Report 2025-12-05; retrieved 2026-07-22 | Primary Judiciary report | High authority for the coroner's stated report-specific concern; does not establish prevalence, current product-wide behaviour or causal contribution beyond the source |
| SRC-222 | NHS England response to Kenneth Cully | Response 2026-06-22; retrieved 2026-07-22 | Official recipient response | Supports NHS England's account of NHS Pathways bleeding questions, training and call-audit controls and intended liaison with Yorkshire Ambulance Service. The predicted triage outcome is not an independently observed system test; liaison and effects remain unverified, and NHS England expressly excludes AMPDS from its oversight. |
| SRC-223 | Sussex Partnership NHS Foundation Trust response to Amy Chapman | Response 2026-06-19; retrieved 2026-07-22 | Official recipient response | Supports the Trust's claimed Record of Time Away and Return/5Cs process, audit inclusion, recording standards, training and handover controls. Policy ratification and continuing monitoring were still pending; compliance and safety effects remain self-reported and unverified. |
| SRC-224 | NHS Greater Manchester response to Joseph Cooper | Response 2026-06-24; retrieved 2026-07-22 | Official recipient response | Supports the ICB's claimed co-occurring-conditions programme, service-specification requirements and no wrong door approach. The crisis-care specification and continued implementation were prospective; reach, compliance and outcomes remain self-reported and unverified. |
| SRC-225 | Department of Health and Social Care response to Joseph Cooper | Response 2026-06-12; retrieved 2026-07-22 | Official recipient response | Supports DHSC's policy account of the 2025 co-occurring-needs framework and ongoing data-sharing work. Statutory guidance, the Single Patient Record and an alcohol-delivery roundtable were future commitments whose delivery, timetable and effects remain planned or unverified. |
| SRC-226 | University Hospitals Sussex NHS Foundation Trust response to Paul Harries | Response 2026-06-05; retrieved 2026-07-22 | Official recipient response | Supports the Trust's claims of an emergency-department imaging-review process, consultant education and audits, GP access to reports and a weekly reviewed AAA database. Notification integration, the vascular pilot and trust-wide EPR remained in development; outcomes are unverified, and the Trust says the AAA database would not have included Mr Harries. |
| SRC-227 | Birmingham and Solihull Mental Health NHS Trust response to Kiefer Fraser-Phillips | Response 2026-06-09; retrieved 2026-07-22 | Official recipient response | Supports the Trust's reported Wi-Fi survey and interim desktop/laptop mitigation, implementation of Dialog+ care planning and strengthened audit arrangements. The permanent connectivity solution and observation audits were still being developed or commenced; coverage, compliance and safety impact remain self-reported and unverified. The landing filename says Foundation Trust, while the response template names NHS Trust. |
| SRC-228 | NHS England response to Hollie Loraine | Response 2026-05-14; retrieved 2026-07-22 | Official recipient response | Supports NHS England's account of suicide-risk Pathways dispositions, urgent clinical review, training and locally determined contact-maintenance practice. NHS Pathways had not reviewed the call recording, regional investigation findings and equipment mitigation are reported second-hand, and operational effectiveness remains unverified. |
| SRC-229 | Rotherham Doncaster and South Humber NHS Foundation Trust response to Delwyn Preece | Response 2026-05-12; retrieved 2026-07-22 | Official recipient response | Supports the Trust's claimed revised leave and documentation rules, additional point-of-care devices, investigator instruction and commencement of contemporaneous-record audits. Late-entry reporting and scheduled leave audits were ongoing or future; compliance and effectiveness remain self-reported and unverified. The landing filename omits and, which appears in the response letterhead. |
| SRC-230 | Ordnance Survey and GeoPlace response to Darryl Johnson | Response 2026-05-19; retrieved 2026-07-22 | Official recipient response | Supports the respondents' fact-finding account that 27B was absent because source records remained unmatched and that NGD Address V3 contains only an unmatched address with an estimated position. National analysis, stakeholder resolution, product adoption and guidance changes were planned, depend partly on local authorities and remain unverified; the published PDF omits its cited Schedules 1 and 2. |
| SRC-231 | Department of Health and Social Care response to Roman Barr | Response 2026-04-20; retrieved 2026-07-22 | Official recipient response | Supports DHSC's account of national urgent-care policy, funding and Release to Rescue, including its acknowledgement that WMAS average handover remained 54 minutes 30 seconds and further progress was needed. It evidences no independently verified case-specific corrective control; implementation and effects of national measures remain self-reported. |
| SRC-232 | Care Quality Commission response to Roman Barr | Response 2026-05-13; retrieved 2026-07-22 | Official recipient response | Supports CQC's claimed internal primary-care reminder, enforcement history and continued monitoring, plus WMAS-reported changes to transport advice and the asthma triage threshold. The operational changes are second-hand within this response, were not independently tested by it, and adoption and outcomes remain unverified. |
| SRC-233 | NHS England response to Roman Barr | Response 2026-04-20; retrieved 2026-07-22 | Official recipient response | Supports NHS England's statement that no specific requirement compels individual SABA-overuse identification, its ongoing respiratory work, the June 2025 asthma-CDSS threshold change and regional handover programme. Provider adoption, adherence, clinical effect and performance outcomes remain self-reported and unverified. |
| SRC-234 | Royal College of General Practitioners response to Roman Barr | Response 2026-06-12; retrieved 2026-07-22 | Official recipient response | Supports RCGP's account of respiratory education and professional description of GP prescribing systems, including the absence of automatic monthly-request or three-inhaler alerts. It lacks case-level treatment information, places ambulance and Pathways issues outside scope, proposes no enforceable remedial control, and uptake and effects remain unverified. |
| SRC-235 | Alternative Futures Group response to Ruairi Stewart | Response 2026-05-01; retrieved 2026-07-22 | Official recipient response | Supports AFG's claims of revised SOPs, DSR templates and task ownership, leave/handover/care-plan audits, a disclosure toolkit and future PSIRF reviews. A cited positive external audit concerned another site, so implementation at Weaver Lodge, cross-site adoption and sustained effectiveness remain principally self-reported and unverified. |
| SRC-236 | Derby City Council and Derbyshire County Council response to Emma Turner | Response 2026-04-23; retrieved 2026-07-22 | Official joint recipient response | Supports the councils' account of a shared safeguarding-adults referral form and acknowledgement that parts of the template could obscure key information. Co-designed revisions were due by the end of July 2026; completion, use and effect on response timeliness remain unverified. |
| SRC-237 | Essex Partnership University NHS Foundation Trust response to Elise Sebastian | Response 2026-04-02; retrieved 2026-07-22 | Official recipient response | Supports EPUT's extensive self-report of autism training, staffing and observation controls, audits, Oxevision oversight and a paper fallback for connectivity loss. The response is not independent assurance of consistent use, record integrity or safety outcomes; the landing filename transposes Partnership University as University Partnership. |
| SRC-238 | Serco response to Gareth Chumber-Kelly | Response 2026-04-07; retrieved 2026-07-22 | Official recipient response | Supports Serco's account that the SASH warning was handed to prison reception and records its dispute that any Serco failing or recurrent document-loss problem was established. It is a respondent position, not independent resolution of the report conflict; proposed discussion through monthly stakeholder meetings does not verify remediation. |
| SRC-239 | HM Prison and Probation Service response to Gareth Chumber-Kelly | Response 2026-04-23; retrieved 2026-07-22 | Official recipient response | Supports HMPPS's claimed digital induction passport, BaSM/DPER enhancements, reception review and suicide-prevention and basic-life-support training measures. Deployment coverage, staff use, document completeness and outcome effects remain respondent-reported and unverified. |
| SRC-240 | West Suffolk NHS Foundation Trust response to Roger Smith | Response 2026-03-31; retrieved 2026-07-22 | Official recipient response | Supports the Trust's account that eCare cannot provide a scalable universal contraindication hard stop, and its proposed clinical-governance, risk-visibility and nursing-escalation alternatives, alongside existing Call 4 Concern and stroke-MDT changes. Planned work, monitoring and safety effects remain self-reported and unverified. |
| SRC-241 | Suffolk County Council response to Anthony Card | Response 2026-02-02; retrieved 2026-07-22 | Official recipient response | Supports the Council's account that MASH is not the appropriate route for mental-health-only concerns below statutory safeguarding criteria, and its planned briefing, guidance updates and participation in a multi-agency audit. It does not establish an end-to-end clinical referral route; delivery and effects remain unverified. |
| SRC-242 | Suffolk Constabulary response to Anthony Card | Response 2026-02-05; retrieved 2026-07-22 | Official recipient response | Supports the Constabulary's account of NHS 111 Option 2 as the intended sub-threshold route, planned vulnerability training and an underway multi-agency audit. Availability, reliable routing, closure and outcomes were not independently tested; scheduled and ongoing measures remain unverified. |
| SRC-243 | General Pharmaceutical Council response to Lyn Maher | Response 2026-03-31; retrieved 2026-07-22 | Official recipient response | Supports GPhC's account of pharmacy inspections, superintendent-led prompt cards and awareness work, early-stage fitness-to-practise investigations, and planned education and Welsh professional communications. It supports wider record access but defers portal requirements to Digital Health and Care Wales; completion, consistent practice and outcomes remain unverified. |
| SRC-244 | HMPPS and Ministry of Justice response to Nigel Feckey | Response 2026-03-25; retrieved 2026-07-22 | Official recipient response | Supports the respondents' policy account of offence-neutrality, local discretion and monitoring of prisoners convicted of sexual offences. It addresses the formal Regulation 28 concern only and provides no evidence of remediation for the digital and information-sharing failures described in the jury narrative; policy operation and effects remain respondent-reported. |
| SRC-245 | Department of Health and Social Care response to Pippa Gillibrand | Response 2026-03-19; retrieved 2026-07-22 | Official recipient response | Supports DHSC's policy account of national maternity work and its statement that operational guidance and home-birth data responsibility sit with NHS England. It largely defers the substantive concerns to NHS England; future investigation, taskforce and action-plan commitments are not evidence of delivery or effectiveness. |
| SRC-246 | NHS England urgent review of homebirth services circular | Circular 2025-11-26; retrieved 2026-07-22 | Official supporting circular attached to the Pippa Gillibrand PFD page | Supports that NHS England instructed provider and ICB nursing and midwifery leaders to review homebirth services after a different PFD concerning Jennifer and Agnes Cahill. It predates the Gillibrand report, required no formal response, and does not prove that any provider completed the review or remedied electronic fallback; it is not counted as a Gillibrand response letter. |
| SRC-247 | NHS England response to Pippa Gillibrand | Response 2026-03-05; retrieved 2026-07-22 | Official recipient response | Supports NHS England's account of its national homebirth review request, existing guidance, work with professional bodies and planned resources and data-development activity. Several controls and data solutions remained prospective; provider action, compliance and outcomes remain self-reported or unverified. |
| SRC-248 | NICE response to Pippa Gillibrand | Response 2026-03-11; retrieved 2026-07-22 | Official recipient response | Supports NICE's account of existing intrapartum, transfer and staffing guidance, areas outside its remit and acknowledged gaps, including electronic-system fallback. It clarifies guidance rather than implementing local controls and does not verify provider compliance, offline resilience or safety outcomes. |
| SRC-249 | HCRG response to Stuart Berry | Response 2026-03-09; retrieved 2026-07-22 | Official recipient response | Supports HCRG's claimed Early Days in Custody nurse role, Prisoner Warning Notice logbook, SystmOne training and audits, and urgent-referral controls. Some measures and the action plan remained incomplete or time-bound; adoption, audit quality and outcomes remain self-reported and unverified. |
| SRC-250 | HM Prison and Probation Service response to Stuart Berry | Response 2026-03-06; retrieved 2026-07-22 | Official recipient response | Supports HMPPS's account of national suicide-risk and reception-training reviews and limited ligature-resistant-cell provision. Reviews and revised training were not complete, ligature-resistant cells were not presented as a complete control, and coverage and effects remain respondent-reported and unverified. |
| SRC-251 | Essex Partnership University NHS Foundation Trust response to Stuart Berry | Response 2026-03-27; retrieved 2026-07-22 | Official recipient response | Supports EPUT's account of sampled audits, MaST's content limitations, mandated care-planning training and planned NOVA EPR/workflow changes, while disputing that the case showed a systemic organisational failure. Several controls remained in development; implementation, audit depth and clinical effects remain self-reported and unverified. |
| SRC-252 | East Midlands Ambulance Service NHS Trust response to Robert Gracey | Response 2026-02-02; retrieved 2026-07-22 | Official recipient response | Supports EMAS's acknowledgement that no Lincolnshire ABD protocol had yet been implemented, its description of NHS Pathways constraints and internal clinical guidance, and intended regional joint work. The protocol remained absent or in development; implementation and outcome effects are unverified. |
| SRC-253 | NHS England response to Robert Gracey | Response 2026-02-23; retrieved 2026-07-22 | Official recipient response | Supports NHS England's technical account of symptom-based NHS Pathways triage, the distinction from MPDS and ongoing national consideration of ABD categories, plus EMAS-reported local MOU review. It does not establish a completed local protocol or category change; operational details and effects remain respondent-reported and unverified. |
| SRC-254 | Lincolnshire Police response to Robert Gracey | Response 2026-04-01; retrieved 2026-07-22 | Official recipient response | Supports the Police's account of regional work with EMAS and a draft joint ABD escalation model. The policy and guidance remained under development, so completion, cross-agency use and effects remain unverified. |
| SRC-255 | Yorkshire Ambulance Service NHS Trust response to Colin Brown | Response 2026-02-06; retrieved 2026-07-22 | Official recipient response | Supports YAS's account that swallowing difficulty was included in the verbal handover and that the ePR was available more than 50 minutes before the choking event, together with proposed clinical alerts, protocol review, learning and exploration of faster electronic risk sharing. YAS was not an interested person at the inquest; its account and planned actions are respondent evidence, not independent resolution or proof of effect. |
| SRC-256 | York and Scarborough Teaching Hospitals NHS Foundation Trust response to Colin Brown | Response 2026-02-18; retrieved 2026-07-22 | Official recipient response | Supports the Trust's claimed immediate soft-diet precaution, sip-testing SOP and training, and planned Nervecentre EPR fields for dysphagia and texture-modified diets. Rollout, consistent use and safety effects remain self-reported or prospective and unverified. |
| SRC-257 | Hampshire and Isle of Wight Healthcare NHS Foundation Trust response to Ethel Robertson | Response 2025-12-23; retrieved 2026-07-22 | Official recipient response from Southern Health's successor Trust | Supports the successor Trust's position that reliable flagging and notification, rather than different computer systems alone, is the principal issue, and records its workload and privacy objections to universal ED checking. It identifies no completed cross-provider notification control and does not independently test the report concern. |
| SRC-258 | Optum response to Alan Mitchell | Response 2025-12-18; retrieved 2026-07-22 | Official recipient response | Supports Optum's counter-position that repeat medication does not expire by default: an authorised user must enable and configure expiry, after which the item moves from Current to Past and remains viewable. This is supplier evidence that materially qualifies the coroner-reported mechanism; it is not independent product testing or a resolution of the source disagreement. |
| SRC-259 | Marine Lake Medical Practice response to Gloria Simon | Undated response; retrieved 2026-07-22 | Official recipient response | Supports the practice's chronology, its account that the care home's request form incorrectly called Riversdale a nursing home, and claimed form, induction, training and Significant Event Analysis actions. The PDF displays no response date; actions, chronology and effectiveness remain respondent-reported and unverified. |
| SRC-260 | Philips response to Melanie Walker | Response 2025-11-17; retrieved 2026-07-22 | Official manufacturer response | Supports Philips's technical account that the factory default ECG-leads-off alarm is medium/yellow with a reminder, that a customer can configure it to low/cyan, and that the hospital setting was reset to default. Philips says it cannot identify when or by whom the local change was made; this supplier account is not independent reconstruction of the event or evidence of product-wide operation. |
| SRC-261 | NHS England response to Melanie Walker | Response 2025-12-17; retrieved 2026-07-22 | Official recipient response | Supports NHS England's account that Greater Manchester ICB reported the monitors had been reconfigured to a persistent yellow warning with a three-minute re-alarm, while referring national device issues to MHRA. The configuration and local mitigation are reported second-hand and their sustained use and effects were not independently verified. |
| SRC-262 | Department of Health and Social Care response to Melanie Walker | Response 2026-01-29; retrieved 2026-07-22 | Official recipient response | Supports DHSC's account that Philips issued a Field Safety Notice about the user-reconfigurable alarm and that MHRA was assessing whether further corrective action or a safety alert was required. That assessment was ongoing; the response does not establish completion, adoption or safety impact. |
| SRC-263 | Care UK response to Thompson Elliott | Response 2025-12-10; retrieved 2026-07-22 | Official recipient response | Supports Care UK's claimed discharge flowchart, policy reinforcement, refresher and eMAR training, named task ownership, daily and weekly handover review and monthly discharge audit. Implementation and examples of subsequent use are self-reported and do not independently establish sustained compliance or outcome effectiveness. |
| SRC-264 | Essex Partnership University NHS Foundation Trust response to Jillian Steedman | Response 2025-12-03; retrieved 2026-07-22 | Official recipient response | Supports EPUT's account of revised information-sharing protocols, structured handovers and shared plans, EPR recording, role accountability, audit and patient-safety review governance. The response addresses many concerns at a high level; implementation, record quality and effects remain self-reported and unverified. |
| SRC-265 | Essex County Council response to Jillian Steedman | Response 2025-12-03; retrieved 2026-07-22 | Official recipient response | Supports the Council's acknowledgement of cross-partner missed opportunities and its claimed Section 117 policy revision and planned community mental-health service review. Both review streams were ongoing; completion, joint operation and effects remain unverified. |
| SRC-266 | Pennine Care NHS Foundation Trust response to Derek Crowther | Response 2025-12-03; retrieved 2026-07-22 | Official recipient response | Supports Pennine Care's account of training oversight and an eObs application being built with offline capability for testing and pilot in 2026. Trust-wide go-live was unknown and the response uses internally awkward prospective wording about the pilot; implementation, data integrity and safety effects remain unverified. |
| SRC-267 | Leicestershire Partnership NHS Trust response to James Cochrane | Response 2025-10-30; retrieved 2026-07-22 | Official recipient response | Supports the Trust's account of SystmOne carer-view capture, carer-support material, a mobile-video data-privacy brief and a planned EHR policy update. Distribution, staff use, consistent incorporation into safety plans and clinical effects remain respondent-reported or prospective. |
| SRC-268 | EMIS response to Venetia Pierce | Response 2025-10-14; retrieved 2026-07-22 | Official recipient response | Supports EMIS's counter-position that patient-specific warnings were displayed, including an age-related warning to monitor lung and liver function, and that MHRA material was accessible through BNF and Safety Check. This supplier account qualifies the specific alert claim but is not independent interface testing and does not resolve what the prescriber saw or used at each decision point. |
| SRC-269 | NHS England response to Jessica Smithson | Response 2025-10-13; retrieved 2026-07-22 | Official recipient response | Supports NHS England's account that ICBs had been asked to commission integrated crisis-text services and that it would review Greater Manchester's response through national PFD governance. It defers local arrangements to the ICB and cannot assure charity governance; rollout, coverage and effects remain unverified. |
| SRC-270 | NHS Greater Manchester Integrated Care response to Jessica Smithson | Response 2025-09-17; retrieved 2026-07-22 | Official recipient response | Supports NHS Greater Manchester's acknowledgement that it did not then commission a crisis-text service and its preferred future model integrated with the NHS 111 mental-health crisis line and local police interfaces. Capacity review, mobilisation and implementation remained prospective; reliable identity, location and pathway performance were unverified. |
| SRC-271 | Department of Health and Social Care response to Jessica Smithson | Response 2025-10-31; retrieved 2026-07-22 | Official recipient response | Supports DHSC's policy account that ICBs had submitted crisis-text plans and that neighbourhood mental-health pilots were underway. It defers operational commissioning to NHS England and Greater Manchester and charity practice lies outside direct control; service delivery and effects remain unverified. |
| SRC-272 | Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust response to John Bell | Response 2025-09-23; retrieved 2026-07-22 | Official recipient response | Supports the Trust's claimed immediate pre-operative review controls, later Datix submission and a broader thematic action plan including electronic referrals and prioritisation governance. The investigation and many actions were still being drafted; the response does not demonstrate a completed control that reconciles cross-specialty EHR decisions. |
| SRC-273 | Department of Health and Social Care response to Lee Dryden | Response 2024-05-20; retrieved 2026-07-22 | Official recipient response | Supports DHSC's delayed policy response, largely relaying NHS England assurance requests about imaging guidance and national ambulance-capacity measures. It provides no independently verified local critical-result control, acknowledgement route or evidence of effectiveness. |
| SRC-274 | NHS England response to Lee Dryden | Response 2023-09-20; retrieved 2026-07-22 | Official recipient response | Supports NHS England's account of imaging-alert guidance, a national webinar, regional assurance requests, reporting standards and digital-imaging infrastructure work. Publication and communication do not demonstrate that external critical results were embedded in a closed-loop local workflow or that outcomes improved. |
| SRC-275 | Royal Wolverhampton NHS Trust response to Margaret McNaughton | Response 2025-09-24; retrieved 2026-07-22 | Official recipient response | Supports the Trust's claimed allergy-policy revision, ePMA hard stops and warnings, training, temporary-staff induction changes and planned recurrent audit. Several measures were awaiting implementation or remained in the action plan; consistent source reconciliation, compliance and effects remain unverified. |
| SRC-276 | Calderdale and Huddersfield NHS Foundation Trust response to Myles Scriven | Response 2025-09-09; retrieved 2026-07-22 | Official recipient response | Supports the Trust's account of learning-disability governance, EPR flags, dashboards, real-time and weekly audits, revised care planning and expanded training. These controls are respondent-reported and do not independently show that recorded reasonable adjustments consistently changed care or improved outcomes. |
| SRC-277 | Royal Cornwall Hospitals NHS Trust response to Jason Clemens | Response 2025-07-22; retrieved 2026-07-22 | Official recipient response | Supports the Trust's confirmation that no digital sepsis alert was then available because Nervecentre could not support one, together with planned e-Care alerting and pathway/SOP work. It is the source for confirmed alert absence; the replacement system, SOPs, adoption and effects were prospective and unverified. |
| SRC-278 | SSP Health (Carlisle Central Practice) response to Thomas Mallinson | Printed response date 2024-07-27; retrieved 2026-07-22 | Official recipient response | Supports the practice's chronology, audits, call-navigation training and position that its staff acted appropriately, while acknowledging fragmented responsibility across services. The printed date predates both the death and PFD and the body calls the report 20 June rather than 30 June 2025; these anomalies materially limit date reliability, and the practice's conclusions are not independent assurance. |
| SRC-279 | North West Ambulance Service response to Thomas Mallinson | Response 2025-09-08; retrieved 2026-07-22 | Official recipient response | Supports NWAS's account that 999 CAD generates a recent-address alert while NHS 111 has no automated repeat-contact alert, and its position that responsibility ended when Cumbria Health accepted the referral. It confirms important boundary limitations but is a respondent interpretation; no reliable return-escalation control or outcome evidence is demonstrated. |
| SRC-280 | Cumbria Health response to Thomas Mallinson | Response 2025-08-20; retrieved 2026-07-22 | Official recipient response | Supports Cumbria Health's account of OPEL escalation, overnight welfare calls, responsibility after acceptance and a hand-back process, with automated Adastra welfare messaging still planned. Implementation status is mixed and capacity, closed-loop operation and effects remain respondent-reported and unverified. |
| SRC-281 | Department of Health and Social Care response to Thomas Mallinson | Response 2025-09-12; retrieved 2026-07-22 | Official recipient response | Supports DHSC's high-level account of the 10-Year Health Plan and proposed NHS 111, 999 categorisation and urgent-care reforms. It does not evidence a case-specific ownership, repeated-contact or failed-referral control; implementation and effects remain prospective and unverified. |
| SRC-282 | NHS England response to Amy Cross | Response 2025-11-26; retrieved 2026-07-22 | Official recipient response | Supports NHS England's account of DPER ownership and commissioning boundaries and planned 2026 pilots giving Liaison and Diversion services direct DPER entry at selected London and West Yorkshire sites. The pilots were prospective and limited; the response does not establish a standard record shared by all police, court and prison healthcare providers. |
| SRC-283 | Essex Partnership University NHS Foundation Trust response to Stephen Neville | Response 2025-12-19; retrieved 2026-07-22 | Official recipient response | Supports EPUT's claimed training, spot checks, new Oxevision audits, dashboard reporting and request to make therapeutic-engagement free text mandatory. The response also acknowledges the field remained non-mandatory and a wider Tendable review was ongoing; completion, qualitative compliance and safety effects remain unverified. |
| SRC-284 | W3C Data Catalog Vocabulary (DCAT) Version 3 | W3C Recommendation 2024-08-22; retrieved 2026-07-23 | Official web standard; data-publication context | Supports exposing dataset distributions, temporal coverage, version relationships, rights and checksums. The Wiki adopts selected disclosure practices but does not claim a conformant DCAT catalogue. |
| SRC-285 | GOV.UK: Define user needs | Retrieved 2026-07-23 | Official government service-design guidance | Supports organising and testing content around reader tasks and evidence needs rather than repository structure; it does not validate the research method or case synthesis. |
| SRC-286 | Campbell Collaboration editorial on evidence and gap maps | Published 2020-03; retrieved 2026-07-23 | Evidence-mapping methods context | Supports matrix dimensions, secondary filters, drill-down and study-record routes. This project remains a targeted case–mechanism/evidence map, not an evidence-gap map or effect-study synthesis. |