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recurance

Derek Cole

26 Mar 2025 · Coroner Samantha Goward · Norfolk

The coroner's concerns

  1. 1. delayed learning from abnormal test results

    “It was accepted that the GP practice, when asked to perform tests by secondary services, should notify them of the results if they are abnormal. It was accepted that it should be confirmed in such circumstances that a follow up appointment is in place and considered whether any abnormal results should lead to a request for a more urgent review. It was also accepted that there was learning for the practice regarding this and that this could be discussed at a Significant Event meeting.”

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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