Skip to content
recurance

Nonie Atshiki

11 Dec 2024 · Coroner Mary Hassell · Inner North London

The coroner's concerns

  1. 1. lack of first aid training for night concierge

    “the night concierge who found Ms [name redacted] had not had any first aid training from St Mungo's”
  2. 2. lack of naloxone training for night concierge

    “the hostel does stock naloxone (used in the emergency treatment of opiate/opioid toxicity), but that the night concierge is not trained in its use”
  3. 3. insufficient night staffing at hostel

    “there are only ever two members of staff working at the hostel at night, of which the night concierge is one”
  4. 4. no CPR attempted on deceased

    “Nobody at the hostel attempted to perform cardiopulmonary resuscitation on Ms [name redacted]”
  5. 5. staff positioned away from medical emergency location

    “the night concierge stayed with her as she lay across the stairs, while the other member of staff stayed by the front door to open it when the ambulance service arrived”

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