Skip to content
recurance

Sally Ellison

27 Apr 2015 · Coroner John Gittins · North Wales (East & Central)

The coroner's concerns

  1. 1. delayed diagnosis of legionella pneumonia

    “although it was clear upon her admission to Glan Clwyd on the 29" of May 2012 at around 16.00 hours, that she was suffering from a severe form of Community Acquired Pneumonia, and that this was recognised as being an atypical pneumonia that same evening, no urine sample was sent for analysis until overnight on the 31" of May with the confirmation of it being positive for legionella coming on the morning of the 1" of June”
  2. 2. lack of rapid legionella testing service

    “should consideration therefore be given to undertaking tests at an earlier stage but there should also be available to the hospital a rapid testing and reporting service, either preferably a service within North Wales or utilising options within organisations geographically closer and more accessible than those in Cardiff”

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