Skip to content
recurance

Kirsty Hendry

20 Oct 2023 · Coroner Alison Mutch · Manchester South

The coroner's concerns

  1. 1. delayed diagnosis of subarachnoid haemorrhage

    “early identification of a burst aneurysm is vital if treatment is to be offered at an early enough stage to reduce the risk of death”
  2. 2. low awareness of subarachnoid haemorrhage symptoms

    “particularly in primary care the symptoms are not readily understood and awareness is often low”
  3. 3. inadequate primary care awareness of burst aneurysm symptoms

    “it was important awareness be raised so that all doctors and other health professionals carrying out examinations in a primary care setting should understand the key symptoms /presentation of a burst aneurysm so that appropriate referrals could be made to secondary care and CT scans be undertaken at an early stage when the probable could be easily identified and treatment options were available”

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