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recurance

Michael Valentine

2 Feb 2016 · Coroner Andrew Cox · Plymouth, Torbay and South Devon

The coroner's concerns

  1. 1. rejected mental health assessment

    “A fax rejecting the request for a mental health assessment wa: io the Surgery.”
  2. 2. failure to discuss re-referral after rejected assessment

    “EM told the Court that there had been a significant events meeting which had looked at the administrative shortcomings in the Surgery. There had been no discussion, however, of her decision not to re-refer following the 10 September telephone contact. Similarly, there has been no discussion of what to do where an application for a mental health assessment has been rejected”

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.

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Michael Valentine · Recurance