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recurance

Lea Hunsley

10 Apr 2018 · Coroner Lisa Hashmi · Manchester (North)

The coroner's concerns

  1. 1. lack of serious untoward incident protocol

    “EAM (a medicallnursing care facility) does not have a serious untoward incident (SUI) protocol”
  2. 2. lack of improvement after CQC recommendations

    “CQC Inspection insufficient action has been taken with regard to the recommendations made within the - last CQC inspection”

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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