Skip to content
recurance

Samia Shara

19 Dec 2014 · Coroner Fiona Willcox · London Inner (West)

A similar concern from this report was raised again 1 time later. See the linked reports.

The coroner's concerns

  1. 1. long and complex calls to emergency services

    “That long and complex calls made to 999 and 111 should be available for audit by the CCG to identify learning opportunities and thus improve outcomes via a quality assurance process.”
  2. 2. downgrading calls to lower acuity

    “That call takers should not be able to downgrade a call by moving to a pathway of lower acuity.”

Linked reports

Raised again laterShanté Turay-Thomas27 Jan 2020 · 5 years 1 month later
Closely relatedConfidence 0.80 · moderate

This report

“That long and complex calls made to 999 and 111 should be available for audit by the CCG to identify learning opportunities”

Later report

“When LCW audited the call in the first instance, the audit identified the problem with the address, but failed to recognise how badly the call had gone in other ways.”
Original on judiciary.uk ↗
Full chain: Inadequate audit of 111 call errors

Responses

No published response was found on judiciary.uk.

  • 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

Samia Shara · Recurance