Skip to content
recurance

John Wilsher

5 Aug 2014 · Coroner Jacqueline Lake · Norfolk

The coroner's concerns

  1. 1. inaccurate discharge letter

    “The information contained in the NNUH Discharge Letter is inaccurate”
  2. 2. unsuitable care home placement

    “Concerns were raised by the GP and a referral made to NCC Community Services on 25 November 2013 as to the suitability of the Care Home in providing care to Mr [name redacted] due to his deteriorating condition”
  3. 3. delayed assessment

    “An assessment was carried out by NCC Community Services on 13 December 2013 by which time Mr [name redacted] had been admitted to NNUH and discharged and plans were already in place for his transfer to a nursing home”
  4. 4. missing nursing assessment outcome

    “The outcome of the Nursing Assessment carried out on 10 December 2013 was not available at the time of the Community Services Assessment”

Responses

2014-0360-Response-by-Norfolk-Norwich-University-Hospitals-NHS.pdf ↗· Norfolk and Norwich University Hospital NHS Foundation Trust

Stated action · beginning of September

“The outcome of that work was presented to our Executive Board at the beginning of September and a series of steps are being put in place to ifmprove the accuracy of discharge information provided to GPs and community services.”
  • 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