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recurance

Gillian Peacock

5 Jun 2024 · Coroner James Thompson · County Durham and Darlington

This report repeats 1 earlier warning. See the linked reports.

The coroner's concerns

  1. 1. important medical information not accessible to clinicians

    “the current system does not address the issue of important medical information being recorded in a patient's notes not being accessible in such a way that clinicians can see and if necessary act on it”

Linked reports

Repeats an earlier warningAgnes Sansom7 Jan 2020 · 4 years 5 months earlier
Closely relatedConfidence 0.90 · high

Earlier report

“existing patient record systems fail to ensure that important and urgent information is brought, in a timely way, to the attention of those who need it”
Original on judiciary.uk ↗

This report

“The use of verbal handovers does not in my view fully address my concern that crucial medical information should be recorded in a patient's medical records in such a way that relevant information is visible to those involved in care.”
Full chain: Patient record system fails to display critical clinical information

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

Gillian Peacock · Recurance