Skip to content
recurance

Peter O'Donnell

20 Mar 2018 · Coroner Simon Nelson · Manchester (West)

The coroner's concerns

  1. 1. lack of formal agreement and documented escalation procedures for independent consultants

    “During the Inquest evidence was heard that:- 1. Whilst an in-patient the care afforded to the deceased was consultant led. The consultant in question was an independent consultant orthopaedic surgeon who confirmed the absence of any formal agreement regarding the criteria in which he would be subsequently called into the hospital to undertake a review of his patient. The consultant maintained that it would be useful to have a document that detailed the circumstances of any future intervention”

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

Peter O'Donnell · Recurance