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recurance

Suzanne Ellerby

14 Nov 2025 · Coroner Anna Loxton · Surrey

The coroner's concerns

  1. 1. lack of follow up of vulnerable patients after transfer

    “Vulnerable patients are often transferred back to primary care by mental health services for their onward care, which is effected by way of a Discharge Letter”
  2. 2. absence of guidance for follow up

    “NHS England has not provided any guidance in respect of expectation for follow up by primary care services when this transfer takes place”
  3. 3. vulnerable patients bear responsibility for follow up

    “In the absence of such guidance, the onus is on vulnerable patients to ensure they follow up their care with their GP, without any safety netting in place should they fail to do so”

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.

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