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recurance

Margaret Connor

9 May 2014 · Coroner Jacqueline Lake · Norfolk

The coroner's concerns

  1. 1. wheelchair without proper pre-use check

    “Insufficient procedures are in place to check wheelchairs before use. Carers collect a wheelchair from an alcove and are required to check over before it is used. It would appear this is not always being done.”
  2. 2. wheelchair missing footplates

    “Wheelchairs are left in the alcove ready for use without footplates, loose footplates and mismatched footplates.”
  3. 3. lack of independent wheelchair inspection

    “There are insufficient/no independent checks being carried out on wheelchairs on their return to the alcove. They are only referred to "the maintenance man' if there is something noted to be wrong with them.”
  4. 4. miscommunication about leg injury

    “The attending Doctors were being told there had been "no trauma" to Mrs [name redacted] leg, despite concerns being raised by her family that her foot/leg had been injured on the wheelchair and despite the faulty plate having been seen by staff.”

Responses

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  • 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.

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Margaret Connor · Recurance