Skip to content
recurance

Sean Heeney

14 Jul 2023 · Coroner Jonathan Dixey · Northamptonshire

The coroner's concerns

  1. 1. narrow corridors and stairs

    “The layout of the building. Witnesses described inter alia: (i) the corridors as being narrow and with 90 degree angle turns; (ii) the stairs as being narrow and steep; and (iii) Mr [name redacted] bedroom as being small and with little space to manoeuvre.”
  2. 2. non-compliance and agitation after Naloxone administration

    “Mr [name redacted] was very seriously unwell. He was described as non-compliant and agitated. When given Naloxone he became increasingly agitated.”
  3. 3. reluctance to cooperate with emergency personnel

    “It is to be anticipated that residents within Approved Premises may be more reluctant to cooperate with emergency service personnel, in particular the police. This may make extrication more difficult.”

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

Sean Heeney · Recurance