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recurance

John Rust

20 Oct 2025 · Coroner Adam Hodson · Birmingham and Solihull

The coroner's concerns

  1. 1. inadequate training on automated CSF drainage systems

    “All clinical staff (medical and nursing) using automated CSF drainage systems such as Liquoguard must have completed adequate training to ensure that they are familiar with the functionality of the device prior to use...”

Responses

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  • NVIDIA Nemotron Nano, Super and Ultra
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  • Qwen3 Embedding 8B on Token Factory
  • Tavily follow-up web search
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  • 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