Skip to content
recurance

Simon Tree

30 Jan 2015 · Coroner Simon Wickens · Surrey

The coroner's concerns

  1. 1. security issues with airlock system

    “- During the Course of the Inquest evidence came to light that whilst the door that [the deceased] left the unit from was now secure, there are security issues with the new airlock system. The Court heard that the onus of releasing people from the unit is placed on ward staff, who operate the airlock system remotely from the ward. Patients have been able to 'tailgate' visitors leaving legitimately and the Court heard 4 people had managed to leave this way in the last 12 months. On one occasion the”

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