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recurance

Christine Neild

2 Oct 2020 · Coroner Alison Mutch · Greater Manchester South

The coroner's concerns

  1. 1. gloves accessible to residents

    “gloves were in open and easily accessible locations throughout the home including in rooms and the kitchen area”
  2. 2. non-food items placed in mouth

    “earlier incident when [the deceased] had put non- food items in her mouth”
  3. 3. absence of sensor alerts

    “no regular use of sensors to alert night staff of a resident getting up and wandering”

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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Christine Neild · Recurance