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recurance

Gabriella Jaiyesimi

26 Aug 2025 · Coroner Mary Hassell · Inner North London

The coroner's concerns

  1. 1. failure to position unconscious person in recovery position

    “no person put her in the recovery position”
  2. 2. absence of pulse checking by staff

    “person ever attempted to check Ms [name redacted] pulse to see if her heart was still beating.”
  3. 3. failure to access onsite defibrillator

    “Nobody thought of fetching one of the store defibrillators.”
  4. 4. passive response to cardiac arrest

    “the security officer said that if he did ever see anyone not breathing in the future, he would wait for the arrival of paramedics”

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.

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