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Sociotechnical coding framework

Cases may receive multiple codes. Codes describe the coroner's concern or a transparent analytical translation; they do not independently establish causation.

Code Domain Operational definition Examples
VIS Information visibility Important information is buried, poorly presented, or unavailable in the view used Abnormal result not prominent; allergy absent from local view
LOOP Action ownership and closed loop No accountable recipient, acknowledgement, escalation, deadline, or completion state Result available but not delivered or actioned
INT Interoperability and continuity Information fails to cross organisational, technical, or geographic boundaries SCR not integrated; EMIS/SystmOne exchange failure
IDPOP Identity, registration and population management Attribution, identity, cohort membership, recall, or longitudinal responsibility is unreliable Screening non-responder not flagged
ALERT Decision support and alerting Alert is absent, excessive, misleading, poorly prioritised, or non-actionable No EPMA suspension alert
HF Human factors and usability Display, workload, cognitive burden, workflow mismatch, or system expectation shapes risk First-page salience; cumbersome access
PROV Data quality, provenance and auditability Entries are incomplete, duplicated, miscoded, copied, overwritten, or amendments are unclear Retrospective amendment not visible
RES Resilience and degraded operation Safety depends on connectivity, manual workaround, fallback, or later reconciliation Telephone-only critical-result escalation
GOV Governance and assurance Policy, procurement, monitoring, standardisation, or learning control is weak Optional safety function not adopted

Coding rules

  • Code only what the report supports. Keep Defence inference out of the mechanism code itself and register controlled downstream translations with REQ- identifiers in the Defence requirements register.
  • Record historical product behaviour with the report date; do not claim it remains current.
  • Distinguish information being stored, available, visible, delivered, owned, actioned, and closed.
  • Use the most specific failure description before assigning broad codes.
  • Mechanism counts are counts of coded reports and may sum above the number of included reports.