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recurance

Katrina Insleay

6 Feb 2025 · Coroner James Puzey · Worcestershire

The coroner's concerns

  1. 1. failure to appreciate pressure sore condition after discharge

    “The absence of a formal, documented handover system between hospital and Neighbourhood Team and the fact that the NT cannot simply check hospital records of patients with pressure sores to verify their condition without specifically requesting records creates the potential for the NT to fail to appreciate the true condition of a patient's pressure sores when they are discharged from hospital and for follow up to be delayed. This increases the risk of wound infection and consequent sepsis.”
  2. 2. insufficiently detailed handover proposals

    “I am informed (letter received from HWHCT on 31.1.25) that there are established handover procedures and that a statement of practice is being drafted to”
  3. 3. potential app may not address concerns

    “an App is being developed which can be used to record and check the condition of pressure sores and that it has the potential to be used across acute and community services”

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.

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