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recurance

Rebecca Gilbank

26 Jul 2016 · Coroner Anna Crawford · Surrey

The coroner's concerns

  1. 1. lack of check at 1.30am on 12 May 2015

    “Lack of check at 1.30am on 12 May 2015”
  2. 2. lack of knowledge about how to obtain an outside line

    “Evidence at the inquest revealed that the staff on duty did not know how to obtain an outside line to call emergency services and, after trying, had to rely on a personal mobile phone. This resulted in a delay of unknown duration”

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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