Skip to content
recurance

Evelyn Smith

12 Sept 2014 · Coroner R Brittain · Warwickshire

The coroner's concerns

  1. 1. inaccurate and inconsistent recording of vital signs

    “The care provided to Miss [name redacted] was reviewed by an independent paediatrician and 4 General Practitioner. | heard evidence that the accurate and consistent recording of Miss [name redacted] vital signs may have allowed earlier recognition of the severity of her illness. | also' heard that the use of the Paediatric Early Warning Scoring system in General Practice may be a useful way of documenting this information. However, it was clear that information in this form is not easy to enter into GP medical”
  2. 2. lack of awareness of croup severity scoring system

    “From the evidence heard at Miss [name redacted] inquest it was apparent that the scoring system for croup severity was not widely known amongst the clinicians involved in her care. However, her GP did learn of this scoring system after reviewing the 'clinical mentor' tool through the practice's computer software. | heard evidence that systems are in place to prompt entry of certain clinical parameters in specific scenarios; predominantly chronic disease review consultations, such as for diabetes and ast”

Responses

Smith-2014-0406a.pdf ↗· Health Education England

  • 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.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error