Skip to content
recurance

Harold Wilberforce

10 Jul 2023 · Coroner Edward Steele · East Riding and Hull

The coroner's concerns

  1. 1. elderly person found fallen at home without medical assessment

    “1) The pharmacy delivery agent attended upon Mr [name redacted] at his home address to deliver his prescription. He had fallen inside the home address and support was provided to him by her. Mr [name redacted] had resisted her attempts to contact the emergency services. Mr [name redacted] was also moved, with the assistance of the prescription delivery agent, from the floor without having been subjected to a medical examination. The prescription delivery agent was, further, unaware of the status of Mr”
  2. 2. lack of training for pharmacy staff on fall response

    “Evidence was provided on behalf of the pharmacy that there was no training provided to staff members in respect of how to deal with and what actions should be taken when a service user is found to have had a fall at their home address by a pharmacy delivery agent. Evidence was also heard that the majority of service users were elderly persons.”
  3. 3. unclear roles and responsibilities for staff attending elderly service users

    “I am concerned that a lack of clarity exists in respect of the roles and responsibilities of persons attending upon the home addresses of elderly service users, particularly in the context of what action should be taken when someone is found to have fallen.”

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