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recurance

Andrew Rees

9 Jan 2024 · Coroner Myfanwy Buckeridge · Avon

The coroner's concerns

  1. 1. broken rescue chain on marina wall

    “in the vicinity of where the deceased was retrieved from the water, the rescue chain on the wall of the marina was broken and that the system of visual inspection in place by Boatfolk Marinas Ltd had not identified this”
  2. 2. lack of formal assessment of change of use

    “a significant change of use but no formal assessment or measure of whether a change of use (e.g. increase in amount or type of footfall/increased cyclists etc.) had taken place was apparent”

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.

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