Skip to content
recurance

Myra Maxfield

25 Oct 2023 · Coroner Emma Serrano · Stoke on Trent and North Staffordshire

The coroner's concerns

  1. 1. delayed access to Tissue Viability Team for pressure ulcer patients

    “it was crucial that patients who were at risk of developing pressure ulcers, had ulcers already, or had developed them whilst in hospital, saw the Tissue Viability Team as soon as possible, and usually within 6 hours”
  2. 2. delays in Tissue Viability Team access

    “delays in doing so, could be causative in the death of patients”
  3. 3. unavailability of Tissue Viability Team over weekends

    “at the Royal Stoke University Hospital, Tissue Viability is not available over the weekend, and this leads to substantial delay in patients being seen”

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

Myra Maxfield · Recurance