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Human-factors lens

Code: HF — human factors and usability.

Scope

Human factors is a cross-cutting way of examining every primary finding, not a residual category for “user error.” It considers the interaction between interface, task, workload, staffing, environment, training, policy, configuration, expectations and fallback. The relevant unit of analysis is the coupled work system.

What the lens reveals in the current series

  • Salience is contextual. In Stephen Rhodes (representative case), first-page presentation and colour were discussed in the context of a high-volume result-review workflow; the report does not isolate interface design as the sole cause.
  • Alert timing can defeat otherwise available decision support. In Marian Grant, the VTE warning was encountered at an ineffective point in the EPR workflow and did not make the unresolved risk persistently actionable. The report and investigation connected the EPR difficulty to the sequence without establishing interface design alone as the cause of death.
  • Access friction changes what becomes routine. In Morris Reddington (representative case), separate credentials and unfamiliar navigation made ambulance-record review operationally difficult even though the record existed.
  • Users choose between representations. Audrey King (representative case) concerns safety-relevant content split between paper and electronic records; Colin Greenway concerns an electronic VTE assessment that was less detailed than the paper tool it replaced.
  • Labels shape expectations about destination. In Stephen Stringer (representative case), route headings did not make clear whether a clinician or administrative team would receive the patient's enquiry.
  • Controls can be bypassed or become noisy. Donald Compton concerns bypass of a known-allergy section, while respondent evidence in Christopher Collinson raises alert-fatigue as a counter-risk to a generic confirmation prompt.
  • Fragmentation increases cognitive and coordination work. Theresa Lydon, Edward Muwanga and Tammy Milward concern safety information distributed across scanned correspondence, multiple platforms or separately held records.
  • Rigid fields and forms can prevent a coherent shared account. Adrian Jennings concerns separate systems and Lorenzo fields that did not readily represent the required clinical context; Patricia Heslop concerns numerous forms, incomplete records and uncertainty about who should complete them. In Heslop, the report expressly stated that the identified delay did not cause or contribute to the death.
  • Change and training alter the meaning users assign to system state. Margaret Spencer concerns follow-up prematurely closed during migration amid unfamiliar workflows and training limitations; Cuthbert Hingert concerns a medication database safeguard that was not used alongside insufficient training. Neither report supports treating “user error” as a sufficient explanation.
  • Work conditions matter. Michael Nye and Elton Deutekom describe, in different settings, night-time or busy understaffed work interacting with notification, monitoring and administrative tasks.

Recurrence, variation and limits

The current review counts show that HF recurs across the targeted series and frequently co-occurs with other codes. This is not a prevalence estimate and does not show that interface design caused every coded death.

Human-factors explanations also vary:

  • a control may be hard to find, easy to misinterpret, burdensome, badly timed or disconnected from the action it requests;
  • adaptation or a workaround may be a rational response to the deployed conditions rather than carelessness;
  • training may mitigate an issue but cannot make an invisible dependency or structurally open loop reliable; and
  • automation can reduce one burden while introducing alert fatigue, automation bias or loss of richer clinical prompts.

Causal conclusions must remain report-specific. Some included reports directly link unavailable information or workflow failures to death; others identify prospective risk, contest the digital interpretation or place it among wider clinical and organisational failings.

Defence implications — analytical translation

The following are analytical translations, not findings made by coroners about Defence personnel or systems:

  • evaluate CORTISONE in representative garrison, deployed, remote, high-volume, cross-boundary and degraded workflows;
  • include all roles that create, route, receive, reconcile and act on information—not clinicians alone;
  • test realistic interruptions, shift change, posting, access friction, missing sources and competing priorities;
  • measure whether users notice, understand, accept and complete safety-critical work, not merely whether a feature is present; and
  • treat workarounds and near misses as evidence about system design and operating conditions.

See the DPHC and Programme CORTISONE analysis.

Evidence basis: included-case dataset, coding framework, and current review counts.