Skip to content
recurance

Paul Moroney

4 Feb 2015 · Coroner John Pollard · Manchester (South)

The coroner's concerns

  1. 1. lack of oxygen saturation monitoring

    “no oxygen saturations were monitored or recorded”
  2. 2. absence of oxygen saturation monitoring

    “Oxygen saturations being monitored”
  3. 3. missing patient oxygen level records

    “no record available to the staff about his previous oxygen levels”

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