Skip to content
recurance

Lorraine Karat

29 Oct 2021 · Coroner Mary Hassell · Inner North London

The coroner's concerns

  1. 1. unassessed balcony access risk

    “No evidence was provided at inquest of a risk assessment having been undertaken of Ms [name redacted] flat, most especially including the window that opened over a metre high onto the balcony, thereby rendering the balcony accessible from within the flat.”
  2. 2. missing balcony railing

    “The balcony was not contained by a railing or other structure to make it safe for use.”
  3. 3. lack of window safety measures

    “There was no sign near the window warning the occupant not to go out onto the balcony and, most importantly, there were no bars on the window or window restrictors to prevent access to the balcony.”

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