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recurance

Jake Robinson

9 Dec 2015 · Coroner Joanne Kearsley · Manchester (South)

The coroner's concerns

  1. 1. missed opportunity to learn lessons

    “The Court heard evidence that his GP had written to Greater Manchester West on the 23TM June 2015 ( exactly to whom this letter was addressed is not known as it was not provided in the evidence from the GP practice) indicating that [the deceased] could be prescribed diazepam following the investigation for his seizure.”
  2. 2. missed opportunity to learn lessons

    “The failure to identify the above issue as part of the review into the death of [the deceased] is a concern as it highlights a missed opportunity to potentially learn lessons.”
  3. 3. lack of prescribing capability

    “The fact that Phoenix Futures have no ability to prescribe medication to their services users was a concern. It meant that young people with substance misuse issues have to be referred to Trafford Aim, who are a service for people over the age of 26. [the deceased] had a good relationship with Phoenix Futures but he did struggle to engage with services.”
  4. 4. disconnected service approach

    “The fact that he then had to engage with two services added to what in the Courts view was a disconnected approach to dealing with Jakes increasing difficulties.”

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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Jake Robinson · Recurance