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recurance

Michelle Dawes

24 Apr 2026 · Coroner Isobel Thislethwait · The Black Country

The coroner's concerns

  1. 1. missed opportunities and delays in care

    “the Trust accept there were missed opportunities and delays in the care provided to Mrs [name redacted] and despite the fact they have identified changes required to improve the care being delivered to their patients, those changes are yet to be implemented and embedded at the Trust”

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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Michelle Dawes · Recurance