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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Earlier report
“At no time during the two periods of Ms [name redacted] inpatient care was she assessed for venous thromboembolism (VTE) risk in contravention of trust policy.”
Raised again
2 years 9 months later
“During the course of [the deceased]'s inquest, I heard evidence which concerns me that there is a lack of clarity in relation to the current local VTE policy.”
Both reports concern deficiencies in venous thromboembolism (VTE) risk assessment linked to trust policy. The earlier report notes missing assessments despite existing policy, while the later report highlights confusion and weakening of the current VTE policy affecting assessments.
Earlier report
“In such cases there is a substantial risk that neither of the conditions will be reported to the DVLA for monitoring.”
The response stated
“The DVLA will continue to work closely with the panel to explore possible options for change to the existing self-declaration system.”
Stated timescale: 8 May 2025
Raised again
6 months later
“(1) The DVLA witnesses confirmed to me that the scheme created by section 94 of the Road Traffic Act 1988 requires that 'licence holders' notify the DVLA if they suffer from a relevant or prospective disability.”
Both reports highlight that reliance on drivers self‑reporting medical conditions to the DVLA can lead to unreported impairments. The earlier case concerns unawareness due to dementia/epilepsy, while the later case concerns deliberate false statements.
Barts Health NHS Trust · NHS body
Governance failure in incident identification and poor quality of clinical notesEarlier report
“A failure in governance at the Trust meant that this case was not identified as a serious incident.”
The response stated
“A specific induction programme has been formulated for the A&E which specifically covers themes such as the mental capacity act, contemporaneous documentation including emergency administered drugs with rationale, sedation and also escalation.”
Raised again
1 year 5 months later
“A failure in governance at the Trust meant that this case was not identified as an incident worthy of investigation through the Patient Safety Framework.”
Same coroner as the earlier report.
Both reports cite a governance failure that prevented the case from being recognised as a serious incident requiring investigation, reflecting concerns that the trust cannot identify, reflect on, and remediate sub‑optimal practice.
Earlier report
“Governance processes at the Trust failed to identify that [the deceased]'s death constituted a patient safety incident until months after her death.”
The response stated
“the Trust has put mitigations in place. The Trust provides mandatory training for all staff including both nursing and medical staff related to the care of patients with a Learning Disability.”
Raised again
11 months later
“A failure in governance at the Trust meant that this case was not identified as an incident worthy of investigation through the Patient Safety Framework.”
Same coroner as the earlier report.
Both reports describe a failure in the trust's governance processes to recognise a death as a patient safety incident requiring investigation. The core concern is the same: inadequate systems for identifying and reporting safety incidents.
Earlier report
“A failure in governance at the Trust meant that this case was not identified as a serious incident. This omission gives rise to a concern that future deaths may follow due to an inability on the part of the trust to identify, reflect upon, and remediate sub-optimal practice”
The response stated
“A specific induction programme has been formulated for the A&E which specifically covers themes such as the mental capacity act, contemporaneous documentation including emergency administered drugs with rationale, sedation and also escalation.”
Raised again
1 year 4 months later
“A failure in governance at the Trust meant that this case was not identified as an incident worthy of investigation through the Patient Safety Framework. This omission gives rise to a concern that future deaths may follow due to an inability on the part of the trust to identify, reflect upon, and remediate sub-optimal practice”
Same coroner as the earlier report.
Both reports cite a governance failure that prevented the trust from recognizing and investigating a serious patient safety incident. They differ in the specific framework referenced (serious incident vs. Patient Safety Framework) and the cases examined.
Earlier report
“I heard evidence at the inquest that this call was graded incorrectly. It should have been graded as a P2 call with a response time within 60minutes. I also heard evidence to confirm that the large number of P1 calls that evening meant that even if the call had been correctly graded it would not have been answered as all available resources were required for the P1 calls (15 minutes response).”
The response stated
“| will ask Home Office officials to contact West Midlands Police to identify if any remedial or additional measures need to be put in place to ensure calls are handled appropriately”
Raised again
6 years 1 month later
“West Midlands Police had insufficient resources to allocate police officers to deal with [the deceased]'s case on 06/01/25 which was classed as a priority case with expected allocation of resources within an hour.”
Same coroner as the earlier report.
Both reports highlight that West Midlands Police lacked sufficient resources to respond promptly to priority calls, leading to dangerous delays.
Earlier report
“There was evidence of poor record keeping on the ward. This included behaviour charts, enhanced patient supervision records and daily evaluation charts not being consistently recorded.”
The response stated
“We have taken the opportunity to review and refine our Enhanced Care Policy and this is proceeding through our governance process for sign off over the coming weeks. One of the changes has been to separate our Falls Risk Assessment and Confusion Risk Assessment to support easier recognition of patients who are either a falls risk or those patients who need a designated level of supervision due to behaviours of concern.”
Stated timescale: coming weeks
Raised again
1 year 5 months later
“Poor documentation, Communication, and systems- There were no clear communication, documentation, or systems in place, to identify if investigations had been performed as requested.”
Both reports highlight inadequate documentation and communication leading to unsafe care. The earlier focuses on general record‑keeping gaps affecting behavior monitoring; the later specifies missing test results and system flaws allowing untracked cancellations.
Earlier report
“ambulance availability is being jeopardised by crews being delayed at hospital when handing patients over to Accident and Emergency staff”
The response stated
“We will be meeting with NEAS in September 2015 to discuss and monitor how they are managing their delivery of the service, what is their current position of staffing levels and identified vacant posts and their current recruitment position.”
Stated timescale: September 2015
Raised again
10 years 3 months later
“delays in ambulances clearing ED was still having a very significant impact on their ability to respond to calls”
Both reports identify delays in ambulance hand‑over at emergency departments as a factor that reduces ambulance availability and impacts response times.
Earlier report
“The delay in an ambulance attending patients due to the unavailability of ambulances.”
The response stated
“The NHS will focus on delivering the following range of practical actions to improve performance in 2025/26: - working towards delivering hospital handovers within 15 minutes, and implementing joint working arrangements that ensure that no handover takes longer than 45 minutes, - improving ambulance 'hear and treat' service rates, including increasing the proportion of Category 2 ambulance incidents where an ambulance clinician provides advice and treatment over the phone, - ensuring all 999 am”
Stated timescale: 2025-26
Raised again
7 months later
“On the day in question across GM some hospitals were taking up to 60 minutes extra over the accepted turnaround time to clear ambulances.”
Both reports identify hospital handover delays as a key factor reducing ambulance availability and delaying responses.
Earlier report
“Due to continuing demand on the ambulance service, an ambulance did not become available until 08.16 hours. The ambulance arrived on scene at 08.26 hours.”
The response stated
“we published our 'Delivery plan for recovering urgent and emergency care services' which aims to deliver sustained improvements in waiting times, including to reduce Category 2 response times (including for serious conditions such as heart attacks and strokes) to 30 minutes on average this year”
Stated timescale: this year
Raised again
1 year 11 months later
“However delays in ambulances clearing ED was still having a very significant impact on their ability to respond to calls including category 2 calls such as the one for Mr [name redacted].”
Both reports highlight excessive ambulance response times caused by delays in hospital handover or turnaround of ambulances. The earlier case describes a >14‑hour wait due to system pressure, while the later case notes that prolonged ED clearance hampers ambulance availability.
Earlier report
“The resources available in the North West Ambulance Service cannot be fully utilised because of the delays in ambulances clearing Accident and Emergency departments caused by the pressure on these departments across the NHS.”
The response stated
“The North West Ambulance Service (NWAS) lead commissioners, representatives from the local health system and NHS England have developed a 6-point winter improvement plan concentrating on key actions to assist in improving performance levels for 999 and Urgent and Emergency Care.”
Raised again
3 years 4 months later
“delays in ambulances clearing ED was still having a very significant impact on their ability to respond to calls including category 2 calls”
Both reports identify delays in ambulances clearing emergency departments as the core problem affecting response to category 2 calls. The later report confirms that this hazard persists despite prior efforts.
Earlier report
“if hospital handover delays didn't exist they would be likely to be meeting their response targets as they did before hospital delays became chronic”
The response stated
“The plan outlined key actions to recover and improve urgent and emergency care services, including: - improving ambulance response times; - increasing ambulance capacity through growing the workforce (for example, increasing clinical capacity in control rooms); - alongside broader system actions to improve flow through hospitals and reducing handover delays; - speeding up discharges from hospitals; - expanding new services in the community.”
Stated timescale: 2023/24
Raised again
1 year 4 months later
“On the day in question across GM some hospitals were taking up to 60 minutes extra over the accepted turnaround time to clear ambulances”
Both reports identify hospital handover delays as a factor that reduces ambulance availability and worsens response times. The later report describes the same mechanism affecting a different region.