Skip to content
recurance

Ralph Goslin

25 Jun 2014 · Coroner ME Hassell · London Inner (North)

The coroner's concerns

  1. 1. sub therapeutic sodium valproate level leading to unrecognised medication failure

    “The junior doctor at St Pancras Hospital who first reviewed the UCH blood test result giving Mr [name redacted] sodium valproate level as less than 3, did not realise that this was sub therapeutic, because the reference range was given as less than 100, rather than 50- 100 as it is in some other hospitals. This meant that Mr [name redacted] failure to take his anti epilepsy medication was not recognised as quickly as it could have been”

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