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recurance

Stuart Tokam

13 Aug 2021 · Coroner Graeme Irvine · East London

The coroner's concerns

  1. 1. delay in arranging clinical assessment

    “There was an unacceptable delay in arranging a clinical assessment of Mr [name redacted]”
  2. 2. lack of triage process for referral acuity

    “There appears to have been no process in place to triage the acuity of a referral and expedite a clinical assessment where necessary”

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