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recurance

Ella David-Fong

30 Jun 2025 · Coroner Lydia Brown · West London

The coroner's concerns

  1. 1. inadequate information for family and carers

    “It was acknowledged at inquest that there is currently inadequate information provided for family and carers regarding this challenging issue”
  2. 2. lack of effective communication of consent and confidentiality requirements

    “Confidentiality and consent are key concepts in establishing the trust necessary to build effective theraputic relationships as well as required under the legal framework.”

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.

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