Skip to content
recurance

Guided path, Step 1 of 4

See a chainStart

Doreen Mattinson

18 Apr 2016 · Coroner Jacqueline Devonish · London Inner North
Check this reportOriginal

The coroner's concerns

  1. 1. insufficient oxygen flow during emergency

    “The London Ambulance Service attended Mrs [name redacted] on 12 November 2015 and made a Safeguarding Report relating to the use of the oxygen. It had been reported that Mrs [name redacted] had been lying supine on the bed saturating at 84% and struggling to breath. The oxygen could not be heard to be running and it was noted that only 1 litre was running when this should have been a15 litre flow with the mask applied.”

Responses

No published response was found on judiciary.uk.

  • 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