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recurance

Dennis Price

23 Jan 2026 · Coroner N Mundy · South Yorkshire East

The coroner's concerns

  1. 1. inpatient post fall review not completed

    “Failure to properly complete the inpatient post fall review”
  2. 2. unclear neurological observation plan

    “No clear plan for frequency of neurological observations and duration of the same and associated lack of clear direction from the attending Doctor following a fall”
  3. 3. ineffective nerve centre escalation completion

    “The efficiency of the Nerve Centre system escalations in that any triggers must be followed up and properly completed on the system for the nerve centre system to be fully effective”

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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