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recurance

Meghan Chrismas

29 Dec 2023 · Coroner Darren Stewart · Surrey

The coroner's concerns

  1. 1. lack of policy guidance arrangements

    “measures which could alleviate this pressure (where someone sources private care) do not exist. There is little or no policy, guidance or other effective arrangements to share important clinical information about patients between private and public healthcare sectors”
  2. 2. delayed detection of missing assistance request

    “The handling of the incident involving Mrs. [the deceased] in Hampshire Constabulary's Force Control Room which resulted in a hour delay in determining that an important communication (being a request for assistance) had not been received by a neighbouring force. This raises concerns as to the effectiveness in the supervision of operators handling the calls and the presence of redundancies or safeguards to detect such circumstances sooner to avoid repetition”

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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Meghan Chrismas · Recurance