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
“Despite having their full complement of ambulance resources staffed and on shift many of them were held up by delays in handover at hospitals;”
The response stated
“I have directed each LHB to develop a local 'six goals' programme plan that incorporated actions to improve ambulance patient handover performance and patient flow, among other local priorities.”
Raised again
1 year 3 months later
“Whilst evidence was received and heard during the Inquest that efforts have been and are still being taken by WAST to improve the situation regarding ambulance delays, there remains significant concerns with Hospital handover delays.”
Both reports highlight that ambulance crews are delayed because patients cannot be handed over promptly at hospitals, causing ambulances to wait outside emergency departments.
Earlier report
“Latimer Court's registered home manager, [REDACTED], conceded in her evidence that neither Mrs. [name redacted] Risk Assessment document, nor her Falls Care plan document were updated following any of these falls”
The response stated
“Following any fall or found on floor incident the falls risk assessment should be reviewed and the falls diary completed. The falls care plan should be updated accordingly and referrals made as appropriate”
Raised again
2 years 4 months later
“It was noted in the evidence, that the observation scores taken for Mr [name redacted] following his fall had not all been recorded in Mr [name redacted] care notes.”
Both reports highlight failures in documenting post‑fall information that should trigger further safety actions. The earlier case concerns missing updates to falls risk assessments and care plans; the later case concerns missing recording of observation scores after a fall.
Earlier report
“[REDACTED] are reportable substances under the Poisons Act 1972. The only obligation under this legislation is that domestic sellers must report reasonable grounds for believing transactions are suspicious.”
The response stated
“The group has worked with businesses, including online suppliers and manufacturers of the substance, to reduce people's ability to purchase it for non-legitimate purposes including suicide, and to raise awareness around safeguarding concerns with businesses where required.”
Raised again
6 months later
“Whilst there is a legal duty on persons selling this substance to report "suspicious" transactions within 24 hours to the Home Office, the purchase of small quantities is being presumed to be connected to the many legitimate uses of the substance”
Both reports identify the same substance as a reportable poison and explosives precursor under the Poisons Act 1972 and highlight insufficient controls to prevent its acquisition for self‑harm.
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
7 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 highlight a failure in the Trust's governance processes to recognize and report a death as a patient safety incident. The core issue is the same: inadequate identification of incidents through governance mechanisms.
Department of Health and Social Care · National body
Inadequate incident reporting and review systemsEarlier report
“In this case the trust's Datix incident reporting system, morbidity and mortality meeting process and SIRMAP procedure were inadequate. Each structure was siloed from the other, leading to inconsistent findings.”
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 later
“In this case the trust's Datix incident reporting system, morbidity and mortality meeting process and PSIRF procedure were inadequate.”
Same coroner as the earlier report.
Both reports highlight that the trust's Datix incident reporting system, morbidity and mortality meeting process, and its safety investigation procedure were inadequate and operated in silos, preventing proper identification and learning from sub‑optimal practice.
Earlier report
“It is clear that there was no strategic plan or collaboration in governance processes.”
The response stated
“The Health Board is now fully reviewing the incident process to identify where it can be improved and strengthened. A workshop was held on the 23rd October 2023 to identify current issues and to begin the work of revising our process. The concerns you have identified in this notice, and in other notices, are being directly fed into this work.”
Stated timescale: April 2024
Raised again
1 year 8 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.”
Both reports highlight governance shortcomings within the organisation that hinder effective incident identification and learning. The earlier report cites a lack of strategic planning and collaboration in governance processes, while the later report points to a governance failure that prevented a case from being flagged for investigation.
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
1 year 6 months later
“(1) Insufficient social care provision leading to large numbers of patients in hospital who are otherwise fit for discharge, thereby impeding patient flow through hospital, there being a direct link between inadequate social care provision and ambulance delays.”
Same coroner as the earlier report.
Both reports identify insufficient social care provision in Cornwall as the root cause of ambulance delays due to blocked hospital discharges.
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 1 month later
“Significant handover delays at RCHT and other southwest hospitals leading to ambulance resources being tied up with increased response delays and increased mortality risks for patients in the community waiting for emergency ambulances.”
Both reports identify hospital handover delays as the cause of ambulance resources being tied up, leading to longer response times and increased risk to patients.
Earlier report
“I am concerned that these continuing delays for ambulances at hospital handovers reflects a risk of deaths into the future.”
The response stated
“the Health Secretary has ordered a full and independent investigation into NHS performance to provide a frank assessment of the issues and challenges it faces”
Raised again
10 months later
“Significant handover delays at RCHT and other southwest hospitals leading to ambulance resources being tied up with increased response delays and increased mortality risks for patients in the community waiting for emergency ambulances”
Both reports identify ambulance handover delays at hospitals as a hazard that ties up resources and increases mortality risk for patients awaiting emergency care.
Earlier report
“Continuing average handover delays (and therefore response delays) which create a risk of future deaths.”
The response stated
“developing local partnership working between the NHS and social care and making sure people get the right support from health and social care services to return home as soon as possible”
Raised again
7 months later
“Significant handover delays at RCHT and other southwest hospitals leading to ambulance resources being tied up with increased response delays and increased mortality risks for patients in the community waiting for emergency ambulances.”
Same coroner as the earlier report.
Both reports identify handover delays in ambulances caused by inadequate social care leading to increased mortality risk. The later report focuses on specific hospitals and observable spikes, while the earlier report discusses average delays and systemic responsibility gaps.
Earlier report
“criteria required by the DVLA and Department of Transport for the issuing and surrendering of driving licences”
The response stated
“the DVLA will also investigate notifications from third parties, including concerned relatives, neighbours, police and health professionals.”
Raised again
7 years 8 months later
“The current system for vehicle licensing relies largely upon the self-awareness of a driver and their willingness and\or ability to self-report medical conditions to the DVLA.”
Both reports highlight that the driver licensing system depends on drivers' own awareness and willingness to report medical conditions that could affect fitness to drive. They note that this reliance creates a risk because some drivers may not self‑report due to fear of losing independence or other barriers.
Earlier report
“Consideration should be given to more frequent, rigorous testing and to consider the duties that should be placed on the driver, their medical practitioners and also family members/carers to report changes in presentation or health to the Driver and Vehicle Licensing Agency.”
The response stated
“the DVLA has published guidance for medical professionals which can be accessed on Gov.uk. The DVLA also provides a dedicated and confidential telephone line for health professionals to contact one of its doctors for case-specific advice or general guidance.”
Raised again
3 years 8 months later
“The current system for vehicle licensing relies largely upon the self-awareness of a driver and their willingness and\or ability to self-report medical conditions to the DVLA.”
Both reports highlight the need for better mechanisms to ensure that medical conditions affecting driving fitness are communicated to the DVLA. The earlier report calls for duties on drivers, clinicians and families to report health changes, while the later report criticises the current reliance on drivers’ self‑awareness and willingness to self‑report.