What breaksFragmentation · Handoff Failure · Unclosed Loop · Missing escalation
SCN-002Coordination breakdown
The Patient Nobody Sees as a Whole.
Every professional may do their job correctly while the patient still falls through the interfaces between them.
ScaleOrganization
UrgencyCritical
Coordination gapHigh
StakesHealth · Life · Service quality
FragmentationHandoff FailureUnclosed LoopMissing escalation
What Koali changes
← Back to the full MosaicKoali gives the episode one governed case with provenance: current state, open questions, decisions, handoffs, follow-ups and responsible roles. Patient and family observations can remain distinct sources while still entering the clinical coordination path.
Who holds part of the picture
patient • family • clinicians
Koali response
Koali gives the episode one governed case with provenance: current state, open questions, decisions, handoffs, follow-ups and responsible roles. Patient and family observations can remain distinct sources while still entering the clinical coordination path.
Real-world parallels
- Martha’s Rule — NHS England
- Québec Ombudsperson — 2024–2025 annual report
What success looks like
The relevant state remains visible across handoffs and time. • Responsibilities, unresolved questions and escalation paths are explicit.
Documented parallels show that the failure mechanism is real; they do not claim Koali would have changed a specific outcome.
The Patient Nobody Sees as a Whole.
Every professional may do their job correctly while the patient still falls through the interfaces between them.
The problem
A patient moves between emergency care, specialists, pharmacy, rehabilitation, home care and family. Each participant sees a valid fragment, but tests, medications, unresolved questions, concerns and follow-ups do not always travel together. The patient or family becomes the integration layer.
What breaks
- Fragmentation
- Handoff Failure
- Unclosed Loop
- Missing Escalation
Who holds part of the picture
- patient
- family
- clinicians
- care coordinators
With Koali
Koali gives the episode one governed case with provenance: current state, open questions, decisions, handoffs, follow-ups and responsible roles. Patient and family observations can remain distinct sources while still entering the clinical coordination path.
Human authority
Authorized humans and institutions retain their existing legal, professional and democratic authority. Koali structures knowledge, coordination and traceability; it does not take sovereign or professional decisions.
What success looks like
- The relevant state remains visible across handoffs and time.
- Responsibilities, unresolved questions and escalation paths are explicit.
- The outcome produces reusable memory for the next comparable case.
Real-world parallels
Martha’s Rule — NHS England
Martha’s Rule followed Martha Mills’s death after family concerns about deterioration were not acted on, creating a direct escalation route to an independent clinical review.
Relation to scenario: DIRECT
Source: https://www.england.nhs.uk/patient-safety/marthas-rule/
Protecteur du citoyen — Rapport annuel 2024-2025
The Québec Ombudsperson documented a case where incorrect assumptions about a care facility delayed rehabilitation after surgery and harmed autonomy and quality of life.
Relation to scenario: STRONG ANALOGUE
Source: https://protecteurducitoyen.qc.ca/sites/default/files/2025-10/rapport-annuel-activites-2024-2025.pdf
Boundary
The documented cases illustrate analogous failure mechanisms. They do not establish that Koali would have prevented the event or guaranteed a different outcome.
Koali loop
signals → shared meaning → evidence → choice → responsibility → action → verification → memory → better knowledge