Skip to content
recurance

Alison Binyon

11 Nov 2024 · Coroner Sophie Lomas · Derby and Derbyshire

The coroner's concerns

  1. 1. uncertainty in moving accommodation

    “communication with service users around moving accommodation needs to be managed carefully as false assurances can undermine trust between the service user and the supporting team”
  2. 2. lack of clear communication policy for moving accommodation

    “lack of evidence of a specific approach or policy addressing how the process can be clearly communicated to those supporting service users in the community”
  3. 3. absence of internal review after death

    “no internal review was carried out at Leicestershire County Council following [the deceased]'s death”

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