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recurance

Irene Whittingham

28 Feb 2020 · Coroner Rachel Syed · Manchester West

The coroner's concerns

  1. 1. inconsistent vitamin D blood level monitoring

    “Conflicting guidance is provided to treating clinicians as to when Vitamin D and Calcium blood level monitoring should be undertaken especially in patients who are given higher (loading) doses of Vitamin D, which exceeds the recommended national guidelines”
  2. 2. confusing dropdown menu allowing incorrect dosing

    “The WellSky and EMIS Software, had a confusing user drop down menu option, which allowed the user to click on a twice daily dose despite the loaded dosage, exceeding national guidelines”

Responses

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  • 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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