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recurance

Jade Rayner

30 Apr 2021 · Coroner Alison Mutch · Greater Manchester South

The coroner's concerns

  1. 1. vulnerable adult with complex mental and physical health needs

    “The inquest was told that her capacity fluctuated and she was vulnerable”
  2. 2. lack of clear multi agency strategy to support her

    “Her case was complex, and the evidence was that there was not a clear multi agency strategy to support her particularly to share information and understand the relationship between earlier Domestic abuse and the subsequent use of alcohol”
  3. 3. existing available alcohol misuse support programmes

    “The evidence was that the existing available alcohol misuse support programmes whilst useful could not meet the needs of a complex case such as this where underlying trauma was a key driver”

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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