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recurance

Jacob Sulaiman

6 Jul 2018 · Coroner Sarah Bourke · London (Inner) North

The coroner's concerns

  1. 1. unrecorded visits

    “Response officers from Careline visited Mr [name redacted] twice during the night of 7/8 December 2017. It is not usual practice to leave a written record of those visits in the property.”
  2. 2. inaccessible contact information

    “Information regarding the nature and number of recent contacts with Wellbeing is not easily accessible to response officers dealing with an emergency call out.”
  3. 3. incomplete service information

    “From the evidence before me, it is evident that the services which visited Mr [name redacted] on the night of 7/8 December 2017 had an incomplete picture of the number of other services that Mr [name redacted] had contacted and his presentation at those times. In particular, had the London Ambulance Service had more information regarding the nature and number of calls that Mr [name redacted] had made to Careline, this may have had some bearing on the steps taken to assess his mental capacity and how Mr [name redacted] was”

Responses

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  • 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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