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recurance

Graham Fox

22 Jun 2018 · Coroner Robert Sowersby · Avon

The coroner's concerns

  1. 1. lack of mandatory clinical response to NEWS scores

    “The standard NEWS documentation contains a list of scores on the left, and corresponding clinical responses in a column on the right. My understanding of the system was that when the relevant score was reached, the corresponding clinical response was mandatory. The impression | gained from listening to the majority of the nursing staff was that there was an element of discretion / clinical judgment to be applied in determining whether the clinical responses that were 'required' when the relevant”
  2. 2. lack of expert evidence on re-triggering practice

    “did not have the benefit of any expert evidence about the process of "re-triggering" patients under NEWS, and | am therefore unable to comment on whether it is clinically appropriate. | did hear evidence that the practice was commonplace within the hospital.”

Responses

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  • 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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