Skip to content
recurance

Hazel Wiltshire

1 Sept 2021 · Coroner Jonathan Landau · South London

The coroner's concerns

  1. 1. lack of monitoring of response times

    “The matron who gave evidence was not aware of obtaining data on response times from the call bell system and had not introduced any other system to monitor response times”
  2. 2. inadequate staffing

    “Staffing levels were inadequate due to higher dependency of patients with Covid”
  3. 3. absence of fall risk assessments

    “Although Mrs [name redacted] was at risk of falls, no risk assessments were completed on any of the three wards in which she stayed”

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

Hazel Wiltshire · Recurance