These are cases where an organisation's published response to a coroner stated an action, and a later coroner then raised the same or a closely related concern with it.
It shows that the concern recurred, not why. It is not a finding that the action was not taken. Newest later report first.
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Department of Health and Social Care · National body
Insufficient social care provision leading to discharge delaysEarlier report
“Insufficient social care provision leading to large numbers of patients in hospital who are otherwise fit for discharge, thereby impeding patient flow through hospital,”
The response stated
“On 6 June 2025, we published our Urgent and Emergency Care Plan for 2025/26. The plan requires the NHS to focus on those activities that will have the biggest impact on improving urgent and emergency care performance, including ambulance response and handover times: - at least 78% of patients in A&E departments will be seen within 4 hours.”
Stated timescale: 6 June 2025
Raised again
1 year 3 months later
“The root cause of the need for the rapid discharge event was inadequate social care provision, this being an ongoing situation.”
Same coroner as the earlier report.
Both reports identify inadequate social care provision as the cause of patients who are medically fit for discharge remaining in hospital, which impedes patient flow and contributes to ambulance delays.
Department of Health and Social Care · National body
Insufficient social care provision leading to discharge delaysEarlier report
“The root cause for ambulance delays was found to be the lack of social care provision in Cornwall, whether care packages or beds in care homes.”
The response stated
“we published our 'Delivery plan for recovering urgent and emergency care services' which aims to deliver sustained improvements in waiting times. Our ambitions for this year are to improve A&E waiting times to 78% of patients to be admitted, transferred, or discharged from A&E within four hours by March 2025, and to reduce Category 2 ambulance response times to 30 minutes on average across this fiscal year.”
Stated timescale: March 2025
Raised again
2 years 9 months later
“The root cause of the need for the rapid discharge event was inadequate social care provision, this being an ongoing situation.”
Same coroner as the earlier report.
Both reports identify insufficient social care provision as the root cause preventing discharge of medically fit patients, which creates hospital congestion and ambulance delays.
Department of Health and Social Care · National body
Insufficient social care provision leading to discharge delaysEarlier report
“Insufficient social care provision leading to large numbers of patients in hospital who are otherwise fit for discharge, thereby impeding patient flow through hospital.”
The response stated
“The NHS planning guidance also includes an implementation target for improving A&E waiting times compared to 2024/25, with a minimum of 78% of patients seen within 4 hours in March 2026 and increasing the proportion of patients admitted, discharged, and transferred from an emergency department within 12 hours across 2025/26 compared to 2024/25.”
Stated timescale: March 2026
Raised again
1 year 4 months later
“The court found significant numbers of patients in hospital who are medically fit for discharge and with no reason to reside in hospital (NCTR) but cannot be discharged due to lack of available social care provision (whether commissioned by social services or NHS).”
Same coroner as the earlier report.
Both reports identify insufficient social care provision as the cause of patients remaining hospitalized despite being fit for discharge, which blocks patient flow.
Barts Health NHS Trust · NHS body
Lack of transport suitability assessment for changing patient conditionsEarlier report
“The failure of RLH transport staff to properly assess the suitability of the venue that a patient is being taken to.”
The response stated
“The departure lounge changed its practice to ensure that the staff document in the patients electronic record in line with trust practice. Confirmation of this has been detailed within the departments most recent version of the Standard Operating Procedure (SOP). At the inquest you were shown this SOP in draft form but | can update you now to say that it has now been signed off by the Royal London Hospital's Executive Board.”
Raised again
5 years 11 months later
“There appears to have been no mechanism to review the suitability of the chosen transport and crew for a patient whose condition has materially changed from the point of booking to the point of transfer.”
Both reports highlight a lack of proper assessment of transport suitability for patients. The earlier focuses on venue assessment at discharge, while the later concerns reviewing transport and crew when a patient's condition changes.
Mid and South Essex NHS Foundation Trust · NHS body
Communication failures and information sharing problems across trustEarlier report
“d. Communication issues with Trust staff and sharing of information”
The response stated
“All Mid and South Essex Hospital NHS Foundation Trust ('MSE') sites have now adopted an electronic prescribing and medication administration (EPMA) platform. EPMA facilitates team members across specialties to record accurately and contemporaneously in one place. The system allows all registered users to clearly see what other medications have been administered and by whom. Staff details are visible against the record so that each interaction is name and date stamped within the patient record.”
Stated timescale: 2025
Raised again
1 year 7 months later
“I am concerned that the documentation and communication failures identified in this case may not be confined to a single ward, clinical team or hospital site.”
Both reports highlight problems with communication and documentation within the Trust. The later report extends the concern to a trust‑wide, systemic issue rather than a single ward.
Earlier report
“Accuracy of record keeping - Training and procedures in respect of how communications should occur between all clinical personnel in the delivery theatre”
The response stated
“The guidelines have been updated to reflect the Royal College of Obstetricians and Gynaecologists recent guideline on Assisted Vaginal Birth (April, 2020)1, this includes a risk assessment to assist with decision making for an assisted vaginal birth, an improved documentation pro forma following an assisted vaginal birth and reference to ensuring that the baby's head is checked immediately at birth for signs of trauma when obstetric instruments have been applied.”
Raised again
5 years 10 months later
“During the course of this investigation I heard evidence of significant deficiencies in the maintenance of clinical records relating to hydration, nutrition, communication, observations, medication management and aspects of clinical decision making.”
Both reports highlight problems with the accuracy and completeness of clinical record keeping. They describe how inadequate records hinder patient safety and investigations.
Earlier report
“The crash location is at the bottom of an incline on the M20 motorway which normally would not cause an issue, however the road also has a camber which causes water to run across the carriageway rather than draining into either the central reservation of the drain on the hard shoulder.”
The response stated
“170 metres of combined kerb drainage jetted, 200 metres x 2 Acco drains jetted and a full CCTV drainage survey carried out”
Stated timescale: 08 February 2023
Raised again
3 years 7 months later
“Despite this fatal collision having occurred in December 2025, the topographic and drainage surveys are not yet available and no works other than "minor works for overburden removal" have taken place”
Both reports highlight inadequate drainage leading to water accumulation on the carriageway that increases the risk of hydroplaning/aquaplaning collisions.
National Highways · National body
Standing water on road leading to hydroplaningEarlier report
“The scene of the collision is in a natural 'bowl' and that, unless effectively drained, it is a point at which standing water will accumulate during and/or after heavy rainfall”
The response stated
“The drainage scheme is progressing as planned through the design and development phases with an estimated start date on the A46 in February 2018. The work will take place over a period of approximately 20 weeks with a planned completion date of June 2018.”
Stated timescale: June 2018
Raised again
8 years 10 months later
“The centralised location of these collisions suggests that there may be ongoing issues with drainage on this section of the road.”
Both reports identify inadequate drainage leading to standing water accumulation on the road as a safety hazard. They link this condition to increased risk of vehicle loss of control.
Care Quality Commission · National body
Inaccurate and inconsistent care plan entries and record keepingEarlier report
“There were concerns that entries contained in Mr [name redacted] care plan were incorrect, including vital information contained on his weight monitoring sheet. Furthermore, the general quality of record keeping was poor.”
The response stated
“We will carry out a further comprehensive inspection within 12 months, to ensure action has been taken and the provider is no longer in breach.”
Stated timescale: 12 months
Raised again
6 years 7 months later
“(1) The record keeping in the home appeasers to be inaccurate and inconsistent”
Both reports highlight problems with inaccurate and inconsistent record‑keeping in care homes.
Care Quality Commission · National body
Inaccurate and inconsistent care plan entries and record keepingEarlier report
“The record keeping was inconsistent and lacked detail on general wellbeing.”
The response stated
“The provider has indicated they have also reviewed the quality of their own documentation and care records. In relation to food records, in addition to improved documentation, staff have also received additional training.”
Raised again
4 years 11 months later
“The record keeping in the home appeasers to be inaccurate and inconsistent”
Both reports highlight problems with record keeping being inconsistent and lacking detail. The earlier report focuses on general wellbeing records, while the later report concerns inaccuracies in incident and handover records.
Department of Health and Social Care · National body
Insufficient social care provision leading to discharge delaysEarlier report
“The root cause for ambulance delays was found to be the lack of social care provision in Cornwall, whether care packages or beds in care homes.”
The response stated
“we published our 'Delivery plan for recovering urgent and emergency care services' which aims to deliver sustained improvements in waiting times. Our ambitions for this year are to improve A&E waiting times to 78% of patients to be admitted, transferred, or discharged from A&E within four hours by March 2025, and to reduce Category 2 ambulance response times to 30 minutes on average across this fiscal year.”
Stated timescale: March 2025
Raised again
2 years 7 months later
“The court found there was insufficient bed availability on acute wards which was attributable to significant numbers of patients in hospital with no reason to reside (NCTR), these being patients who are medically optimised but cannot be discharged due to lack of onward care support.”
Same coroner as the earlier report.
Both reports identify insufficient social care provision as the root cause of patient flow blockages in the hospital system. The earlier report links this to ambulance handover delays, while the later report links it to emergency department overcrowding.
Department of Health and Social Care · National body
Insufficient social care provision leading to discharge delaysEarlier report
“Insufficient social care provision leading to large numbers of patients in hospital who are otherwise fit for discharge, thereby impeding patient flow through hospital”
The response stated
“On 6 June 2025, we published our Urgent and Emergency Care Plan for 2025/26. The plan requires the NHS to focus on those activities that will have the biggest impact on improving urgent and emergency care performance, including ambulance response and handover times: - at least 78% of patients in A&E departments will be seen within 4 hours.”
Stated timescale: 6 June 2025
Raised again
1 year 1 month later
“Data indicates that RCHT have been failing to meet the 4-hour target for a significant number of patients.”
Same coroner as the earlier report.
Both reports identify insufficient social care provision as causing patients to remain in hospital who are ready for discharge, which disrupts hospital flow. The earlier report links this to ambulance delays, while the later report emphasizes ED crowding and delayed ward care.