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recurance

Saif Hussain

25 Nov 2021 · Coroner Heidi Connor · Berkshire

The coroner's concerns

  1. 1. inconsistent drug administration without safeguards

    “The trust should consider : 1. A single system for record keeping and monitoring. 2. How the system could incorporate appropriate limits on the administration of certain drugs within that system. 3. Whether software like Guardrails should be implemented more widely, and consideration given to when and how it is possible to override this, and how that should then be documented. 4. Adopting a system of flagging up where prescription and administration of drugs is different.”

Responses

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  • 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.

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