Skip to content
recurance

Ian Cockfield

25 May 2022 · Coroner Graeme Irvine · East London

The coroner's concerns

  1. 1. patient fall resulting in head laceration

    “On Sunday 11th July 2021, Mr [name redacted] was discharged from hospital after treatment. The patient was discharged to a mental health ward at a different hospital. Upon arrival at the mental health ward at 16.00hrs, a review of the patient's falls risk assessment was not undertaken. The following day, Mr [name redacted] suffered a fall whilst mobilising, unsupervised by staff. Mr [name redacted] sustained a serious laceration to his head.”

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.

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