Skip to content
recurance

Guided path, Step 1 of 4

See a chainStart

Clara Freeman

26 Mar 2021 · Coroner Stephen Hugh Glossop Covell · Plymouth Torbay and South Devon
Check this reportOriginal

The coroner's concerns

  1. 1. inadequate staff proficiency in emergency response

    “Evidence was heard regarding the level of proficiency of the care and nursing staff in dealing with the care of the Deceased after her fall and the interaction of staff with the ambulance service control centre call handlers, particularly in the passing of relevant information and any changes in the Deceased's condition.”

Responses

2021-0085-Response-from-Hart-Care-Redacted.pdf ↗

  • 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

Clara Freeman · Recurance