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recurance

Norma Tellam

2 Dec 2024 · Coroner Stephen Covell · Cornwall & the Isles of Scilly

The coroner's concerns

  1. 1. transfer to wrong hospital for orthopaedic follow up

    “Although Mrs [name redacted] was under the care of Royal Cornwall Hospital and awaiting a post operation follow up, when clinical staff at Liskeard Community Hospital had concerns about a possible infection at the site of the surgery Mrs [name redacted] was taken to Derriford Hospital rather than to the orthopaedic team at the Royal Cornwall Hospital who had recently operated on her”
  2. 2. transfer to wrong hospital for hip surgery follow up

    “When Mrs [name redacted] had recovered from a chest infection she was transferred from Derriford to Liskeard Community Hospital for further rehabilitation rather than to the Royal Cornwall Hospital for follow up on the developing problems with the fixing metalwork at the site of the hip surgery”
  3. 3. lack of continuity in clinical care during transfers

    “Decisions relating to the transfer of Mrs [name redacted] between Liskeard Community Hospital and Derriford Hospital did not give sufficient weight to continuity of clinical care”

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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Norma Tellam · Recurance