Skip to content

Source register

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 2026-07-15 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, 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