Skip to content
recurance

Ruth Milne

16 May 2017 · Coroner Paul Cooper · South Lincolnshire

The coroner's concerns

  1. 1. lack of continuity and appropriateness of medical staff dispatched by GP

    “The lack of continuity and the appropriateness of the medical staff despatched by the GP's ail Hawthorn Medical Practice, Skegness. The Safeguarding report _ ohnstone Head of Safeguarding dated November 2015 identified this.”
  2. 2. unimplemented action plan monitoring and recommendations from safeguarding report

    “really need to know if all the Action Plan, Monitoring and recommendations' (on page 11 & 12) of the safeguarding report have now been implemented and if not why not.”

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