Skip to content
recurance

Martin Ormond

17 Feb 2026 · Coroner Alan Wilson · Blackpool & Fylde

The coroner's concerns

  1. 1. decisions made without complete ECG interpretation information

    “At the GP surgery, a GP made decisions in the absence of the necessary information - notably two reports submitted by an external company asked to interpret an ECG trace - and it did not seem that there was an effective process in place to ensure GPs are provided with the necessary information”
  2. 2. important additional information not reaching GP before decisions

    “In the event the external company decides to submit an amended report, there appeared to be no effective process in place to ensure what may be important additional information reaches the relevant GP before important decisions are made regarding patients”

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