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recurance

Aviva Otte, Oscar Barker and Yousef Al-Kharboush

15 Nov 2024 · Coroner Julian Morris · London Inner (South)

The coroner's concerns

  1. 1. lack of mandatory reporting of adverse events by section 10 entities

    “There is no requirement for a section 10 exempt entity to report any of its findings to the MHRA or indeed to other Trusts or the industry in general if an adverse event occurs”
  2. 2. commercial organisations may not share risk information

    “the same may also be true of commercial organisations but they have the power of the MHRA controlling and effecting recalls and actions and the wider dissemination of information”

Responses

  • Built with
  • NVIDIA Nemotron Nano, Super and Ultra
  • Nebius Token Factory inference
  • Qwen3 Embedding 8B on Token Factory
  • Tavily follow-up web search
  • Postgres and pgvector search
  • Next.js site

Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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Aviva Otte, Oscar Barker and Yousef Al-Kharboush · Recurance