Example Governed Decision Record
Companion artefact
This is a concrete example of a Governed Decision Record as produced by OMEGA. It shows how a real-world decision is captured in a form that can be inspected, challenged, and audited.
This example is intentionally distinct from the safeguarding, engineering, and financial examples to demonstrate cross-domain consistency of the underlying record structure.
This is a stylised example. It is structurally accurate but not authoritative clinical guidance.
GOVERNED DECISION RECORD
Record ID: omega-record/2026-05-06/bht-burns-0047
Schema Version: omega/1.0
Domain: clinical.burns.triage
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CONTEXT
A 34-year-old patient presents to a district general
hospital A&E at 14:28 with thermal burn injuries
sustained 90 minutes earlier in a domestic kitchen
fire.
Patient is conscious, distressed, in moderate pain
(8/10). Burns visible on left forearm, anterior
chest, and partial face. Estimated total body
surface area affected: 12-15%. No airway compromise
observed at presentation.
Initial triage category recorded as urgent. Wound
photographs taken for transfer handover. Analgesia
administered under local protocol while specialist
referral criteria were checked.
The treating clinician must decide on disposition:
local admission, transfer to specialist burns unit,
or treat-and-discharge with outpatient follow-up.
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DECISION
Transfer to specialist burns unit (Stoke Mandeville
Hospital, Buckinghamshire) for assessment and
admission.
Decision time: 14:42
Time elapsed from presentation: 14 minutes
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REASONING
The decision was made by applying NHS England burn
referral criteria to the observed presentation.
Three factors triggered the transfer threshold:
1. TBSA estimate exceeds 10% (the standard
specialist referral threshold for adult burns)
2. Burns involve a "special area" (face)
3. Mechanism of injury (kitchen fire, enclosed
space) carries inhalation injury risk that
may not yet be apparent
Local admission was considered but rejected: the
combination of TBSA estimate, facial involvement,
and inhalation risk exceeds the safe boundary for
non-specialist care. Treat-and-discharge was
considered but rejected: pain control requirements
and risk of delayed airway compromise make
ambulatory management inappropriate.
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EVIDENCE AND ASSUMPTIONS
Evidence used:
- Direct visual assessment by treating clinician
- Triage record and wound photographs taken at
14:31 for receiving-unit handover
- Patient-reported mechanism (kitchen fire,
approximately 5 minutes exposure before escape)
- Observed vital signs (BP 138/85, pulse 102,
SpO2 98% on air, respiratory rate 18)
- NEWS2 score 1 at presentation; repeat
observations scheduled every 15 minutes pending
transfer
- Pain assessment (8/10 verbal numeric scale)
- Analgesia administered under local emergency
department protocol
- Time since injury (90 minutes)
Assumptions explicitly recorded:
- TBSA estimation accuracy: ±3% (visual
assessment under A&E lighting; depth estimation
may underestimate full-thickness involvement)
- Inhalation injury status: not currently
detectable, but exposure history warrants
elevated suspicion
- Patient consent capacity: assumed intact
(patient alert, oriented, able to communicate
preferences)
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AUTHORITY
Decision authorised by: Dr. [Treating Clinician],
A&E Specialty Doctor, BHT NHS Trust
Authority basis: NHS England Adult Burn Referral
Criteria (current version), under standing
delegation for emergency burn triage decisions.
Specialist consultation obtained: Yes
- Stoke Mandeville Burns Unit registrar contacted
14:38, transfer accepted 14:41
- Receiving consultant: [name]
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CONSTRAINTS CHECKED
The following constraints were evaluated before
the decision was committed:
✓ Patient meets specialist referral criteria
✓ Receiving unit has capacity (confirmed by call)
✓ Transfer logistics available (ambulance ETA
20 minutes)
✓ Patient consents to transfer (verbal consent
obtained, capacity assessed)
✓ Pre-transfer stabilisation requirements
achievable locally
⚠ Distance to specialist unit (47 miles),
flagged for review but does not block transfer
given clinical indication
⚠ Reassessment triggers defined: respiratory
rate increase, voice change, soot in sputum,
oxygen desaturation, increasing facial swelling,
uncontrolled pain, or ambulance delay beyond
45 minutes triggers immediate senior review
before transfer
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DISPUTES
One disagreement was recorded during this decision.
Senior nurse on duty queried whether local
admission with overnight observation might be
sufficient, given patient's apparent stability and
the geographic burden of transfer. The query was
considered: local admission would defer specialist
assessment by 12-18 hours; current presentation
includes risk factors (face, mechanism) that may
deteriorate in that window without specialist
intervention.
Resolution: transfer proceeded. Senior nurse's
concern noted in record. Transfer coordinator
confirmed that escalation to a critical care crew
would be requested if airway observations changed
before departure. No clinical override was required.
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CONSENT
Patient consent recorded for:
- Transfer to specialist unit
- Specialist burns unit assessment and treatment
- Communication of clinical record to receiving
team
Patient consent NOT obtained for (and not required
for current decision):
- Specific surgical interventions (separate
consent at receiving unit)
- Research data inclusion (separate process)
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HARM TRACE
Anticipated harm chains evaluated:
If transfer proceeds (chosen path):
- Risk: 90-minute transit during which condition
could deteriorate
- Mitigation: paramedic crew briefed, pre-transfer
stabilisation completed, receiving unit prepared
- Residual risk: low to moderate
If local admission (rejected path):
- Risk: delayed specialist assessment of facial
burns and inhalation exposure
- Risk: limited burns expertise in local team
- Residual risk if pursued: moderate to high
If treat-and-discharge (rejected path):
- Risk: delayed presentation if condition
deteriorates
- Risk: inadequate pain management
- Risk: missed inhalation injury
- Residual risk if pursued: high
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OUTCOME
Recorded at 18:45 (4 hours post-decision):
Patient transferred without complication. Minor
delay (12 minutes) in ambulance arrival due to
availability constraints. Specialist burns unit
assessment confirmed:
- TBSA 13% (consistent with field estimate)
- Mixed-depth burns including partial-thickness
and superficial dermal
- No inhalation injury identified
- Facial burns superficial
Treatment commenced. Patient admitted to burns
unit ward.
Pre-transfer observations remained stable during
the ambulance delay. No reassessment trigger was
met before departure.
The decision is closed with outcome COMMITTED.
No retrospective review flagged.
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PROVENANCE
Content hash:
sha256:7a3f2c8e1b9d4a5c6e2f8b1d3a9c4e7f5b2a8d1c9e3f6a7b4c8d2e1f5a9b3c6d4e7f2a8b1c5d9e3f
Previous record hash:
sha256:4b8d2e1f7a5c9b3d6e4f8a2c1b9d5e3f7a4c8b2d6e1f9a3c5b8d4e2f7a1c9b3d6e8f4a2c5b1d7e9f
(preceding record in BHT burns triage chain)
Schema validation: passed (omega-contracts v0.2.2)
Cryptographic seal: valid
Composition: substrate_native_records →
omega_records (canonical envelope)
The substrate paper describing the underlying architecture is available at /substrate/.