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.

Care-pathway coding

Care-pathway fields answer a different question from the primary browsing context. They identify the settings involved, where the safety-relevant information or work item arose, where action was expected, and where the workflow failed. They do not identify which organisation caused the death.

Controlled setting codes

Code	Setting or pathway participant	Broad care-level interpretation
`PATIENT_HOME`	Patient or home	Outside a provider setting
`PRIMARY_CARE`	General practice, primary out-of-hours care or an equivalent first-contact service	Primary
`COMMUNITY_HEALTH`	Community nursing, rehabilitation or urgent community response	Community
`AMBULANCE_URGENT`	Ambulance, NHS 111, emergency call handling or urgent response	Urgent/emergency pathway
`SECONDARY_ACUTE`	Acute hospital, emergency department or hospital outpatient service	Secondary
`TERTIARY_SPECIALIST`	Regional or remote specialist service	Tertiary/specialist
`COMMUNITY_MENTAL_HEALTH`	Community mental-health or crisis service	Community/specialist; do not force into primary or secondary
`INPATIENT_MENTAL_HEALTH`	Inpatient or secure mental-health service	Secondary/specialist
`PHARMACY`	Community, online or hospital-linked pharmacy/dispensing service	Distinct medicines setting
`DIAGNOSTIC_SERVICE`	Laboratory, radiology, imaging or other diagnostic service	Care level depends on the report; retained separately
`MATERNITY_COMMUNITY`	Community midwifery or primary maternity interface	Community/primary interface
`MATERNITY_ACUTE`	Labour ward, obstetric or neonatal hospital service	Secondary/specialist
`PAEDIATRIC_ACUTE`	Acute paediatric service	Secondary/specialist
`SECURE_CUSTODIAL`	Prison, custody or secure healthcare	Secure setting; may include primary-like and specialist functions
`SOCIAL_CARE`	Care home, supported living, homecare or local care support	Social care
`NATIONAL_SERVICE`	National programme, guidance, registry or central service	National-to-local layer
`NON_HEALTH_AGENCY`	Police, local authority operational service or another non-health agency	Non-health sector
`PRIVATE_HEALTHCARE`	Private hospital, imaging or other private provider	Independent sector; care level retained in the note where relevant
`MULTIPLE`	More than one material origin or destination	Used only for origin/destination; never in `settings_involved`
`UNCLEAR`	Source does not support a more specific assignment	Used only for origin/destination

settings_involved is a unique, non-exclusive pipe-delimited set. It records material participants but is not an ordered event sequence and cannot represent a return leg by repeating a code. information_origin_setting and information_destination_setting use one controlled code or MULTIPLE/UNCLEAR. MULTIPLE may represent several services of the same controlled type; it therefore does not require several distinct settings_involved codes. The displayed transition pattern is derived from the origin and destination fields.

Origin and destination care contexts

The non-exclusive origin_care_contexts and destination_care_contexts fields provide the explicit primary/secondary roll-up. They preserve contexts that should not be forced into that distinction.

Code	Care context
`PATIENT_PUBLIC`	Patient, family, carer or public origin/destination
`PRIMARY`	Primary care
`COMMUNITY`	Community health, community mental health or community maternity care
`AMBULANCE_URGENT`	Ambulance, NHS 111 or urgent response
`SECONDARY`	Secondary acute, inpatient mental-health, acute maternity or acute paediatric care
`TERTIARY_SPECIALIST`	Tertiary or specialist care
`DIAGNOSTIC`	Laboratory, imaging, radiology or other diagnostic service
`PHARMACY`	Pharmacy or dispensing service
`SOCIAL_CARE`	Social care, care home or supported living
`NATIONAL_SERVICE`	National programme or service
`NON_HEALTH`	Police, local authority operational service or another non-health agency
`SECURE_HEALTHCARE`	Prison, custody or secure healthcare; not forced into primary/secondary
`PRIVATE_HEALTHCARE`	Private healthcare where the source does not support a more specific level
`UNCLEAR`	Source does not support a reliable context

If a row has several material origins or destinations, it records every supported context once. Several providers in the same context therefore retain a single context value. For a single controlled origin/destination setting, the care context must be the corresponding single roll-up.

Care-setting span

Code	Definition
`ONE_CARE_SETTING`	The pathway involves one care-service setting; an external patient, national or non-health participant does not itself increase this count
`MULTIPLE_CARE_SETTINGS`	The pathway involves two or more distinct care-service settings, including distinct services within the same broad care context
`NO_CARE_SETTING`	No care-service setting is represented
`UNCLEAR`	The report does not support a reliable span classification

Social-care services count as care settings for this span. Patient/home, national-service and non-health-agency participants do not. The span is independent of information medium and sector: a paper/digital hybrid can involve multiple care settings.

Sector boundary

Code	Definition
`HEALTH_ONLY`	Material service participants are confined to health services; patient/public involvement does not change the sector classification
`HEALTH_SOCIAL_CARE`	The pathway crosses health and social care
`HEALTH_NON_HEALTH`	The pathway crosses health and another non-health sector
`HEALTH_SOCIAL_AND_NON_HEALTH`	Health, social care and at least one other non-health sector are material
`SOCIAL_CARE_ONLY`	Material service participants are confined to social care
`SOCIAL_AND_NON_HEALTH`	Social care and at least one other non-health sector are material without a health-service participant
`NON_HEALTH_ONLY`	Material service participants are confined to non-health agencies other than social care
`UNCLEAR`	The report does not support a reliable sector classification

Failure point

Code	Definition
`ORIGIN`	Unsafe creation, configuration, recording or release at the originating service
`TRANSFER`	Loss, distortion, delay or missing ownership at an interface or handover
`DESTINATION`	Information arrives or exists but is not visible, interpreted, owned or actioned by the receiving service
`MULTIPLE`	Material failure is distributed across more than one point
`UNCLEAR`	The report does not permit a reliable assignment

Coding rules

Define “origin” as where the safety-relevant information or work item arose, not where the death occurred and not an attribution of fault.
Define “destination” as the service or setting expected to review, reconcile or act.
Use MULTIPLE only when the source supports materially distributed origins or destinations; use UNCLEAR when it does not.
Code settings and span from the report-specific pathway, not from the organisation receiving the PFD.
Keep care-setting span separate from paper/electronic medium and from the predominant legacy boundary field.
Record high, medium or low classification confidence with a concise source-linked note. This is not source authority, causal certainty or independent review.
Reopen the primary report when the existing clinical_setting and care_transition fields do not resolve the coding.
Report aggregate pathways only as recurrence within the targeted included dataset.