Skip to content
recurance

Catherine Best

15 Jul 2021 · Coroner Aled Gruffydd · Swansea, Neath & Port Talbot

The coroner's concerns

  1. 1. inadequate nasogastric feeding regime

    “There was an inadequate regime of supplemented feeding by way of nasogastric tube meaning that [name redacted] was not receiving a consistent amount of calories per day to increase the chances of fighting infection. [name redacted] was a challenging patient and it could not be guaranteed that [name redacted] would always take her meals thus ensuring that her calorie intake was obtained orally.”

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