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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Greater Manchester Integrated Care Board · Commissioner
Insufficient safeguards in long term opioid prescribingEarlier report
“However despite the risks opioid painkillers presented to him he had been started in primary care on opioid based painkillers for reported pain. He had become addicted to them and took them at increasing levels topping them up with non-prescribed opioids.”
The response stated
“Archwood Medical Practice have undertaken an audit of their patient records to identify all patients with a history of drug addiction. A 'pop up' alert will be added to each identified record to ensure that anyone consulting with a patient within this cohort is immediately aware of the history and can therefore consider this history within their clinical decision making.”
Raised again
6 months later
“[the deceased] had been prescribed opiates for many years despite the risks associated with long term opiate prescribing. The evidence before the inquest was that there had been very limited attempts to review the long term prescribing of opiates to her.”
Same coroner as the earlier report.
Both reports highlight insufficient safeguards when prescribing opioids, specifically a lack of proper assessment or monitoring of patients receiving opioid medication.
Department of Health and Social Care · National body
Lack of staff training in cardiac arrest recognition and first aidEarlier report
“The adequacy of the training of Emirates staff in respect of the recognition of possible cardiac arrest and signs thereof including agonal breathing and the administration of appropriate first aid/prompt CPR”
The response stated
“I am advised that work is underway to increase the training of the Fire Service to Extended Community First Responder levels.”
Raised again
7 years 7 months later
“That there is difficulty in lay people (trained or not) including ambulance call handlers in understanding the signs of agonal breathing or cardiac arrest”
Both reports highlight problems with recognizing agonal breathing or signs of cardiac arrest. The earlier issue concerns airline staff training, while the later issue concerns lay people and ambulance call handlers' understanding.
Earlier report
“Evidence at the inquest confirmed that the greatest charice of survival following an arrhythmic out of cardiac arrest is with early defibrillation and CPR.”
The response stated
“We are currently working with the Department of Health to oversee the distribution of £1,000,000 funding for public access defibrillators across communities in the UK.”
Raised again
8 years 6 months later
“POINT C: That there is a need for better understanding of the use of defibrillators particularly by lay persons and trained first aid persons”
Both reports highlight a deficiency in public knowledge and use of defibrillators for cardiac arrest. The earlier report stresses the need for more public access defibrillators and education, while the later report focuses on improving understanding of defibrillator use by lay and trained responders.
Earlier report
“The Health Board's Transfer of Care document at the time the transfer occurred did not include any detail or process as to how the transfer should occur.”
The response stated
“incidents. The Transfer and Discharge of Care Protocol has been revised to include explicit guidance relating to transfers of care between community teams. This includes the steps to be taken by the care coordinator, supporting administrative staff and the single point of access service (SPOA). Progression of this protocol through the Health Board ratification process is being led by the MH&LD Deputy Director of Nursing and progress is overseen by the MH&LD Policy and Procedure Group. The revised protocol”
Stated timescale: end of January 2024
Raised again
1 year 7 months later
“That the process of assessment by the Nursing Home prior to the transfer of care to them was not sufficiently robust so as to ensure that all relevant information required for the safe care of a patient had been received and assessed”
Both reports highlight deficiencies in the transfer of care process that could compromise patient safety. The earlier report focuses on missing detail in the Transfer of Care document, while the later report concerns inadequate pre‑transfer assessment by the nursing home.
Earlier report
“There seems to be very little oversight of these businesses in their provision of cold water immersion covering matters such as pre-session health advice or warnings, public liability insurance, training and experience”
The response stated
“I have asked that this matter is raised at the national Local Authority Health and Safety Practitioner Forum”
Raised again
1 year 6 months later
“It became clear in evidence that the activity does not require a licence from the Adventure Activities Licensing Authority and can be undertaken and/or organised by anyone without regulation.”
Both reports highlight a lack of oversight and safety guidance for unregulated water‑based activities offered to the public. The earlier report focuses on cold‑water immersion businesses, while the later one concerns open‑water swimming events, but the core concern about missing regulation and risk management is the same.
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
9 months later
“significant delays in the handover from the ambulance to the ED team. This was due to pressure on the ED but meant that ambulances were tied up for longer than necessary and then had a knock on impact on the ability of the ambulance service to respond to calls.”
Both reports highlight delays in handing over patients from ambulances to emergency departments as a safety concern. These delays tie up ambulances and reduce the service’s ability to respond to further calls.
Department of Health and Social Care · National body
Inconsistent iv fluid administration and inadequate shock managementEarlier report
“IV fluids were not administered consistently. The longest period in which fluids were not administered was 17 hours and 45 minutes.”
The response stated
“Cross site audits have been completed on COTE (Care of the Elderly) wards on a random basis to understand a cross section of compliance with fluid management with no notice given to the ward in advance of the audit. The audits capture patients who are on fluid restriction, patients requiring oral and intravenous hydration, parenteral nutrition and output monitoring, whether the intake and output is entered on Careflow Vitals and appropriate action taken as necessary. The audits were completed by”
Stated timescale: completed
Raised again
2 years 2 months later
“Intravenous fluids were commenced but these were not targeted against response. [the deceased] remained hypotensive and tachycardic despite the fluid administration.”
Both reports highlight problems with intravenous fluid management in the trust, specifically failures to administer or monitor fluids appropriately.
Earlier report
“During the inquest evidence was given that 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
9 years 10 months later
“Significant handover delays leading to ambulance resources being tied up at hospital with increased risk in mortality for patients in the community waiting for emergency ambulances”
Both reports highlight that ambulance crews are delayed when handing patients over to hospital staff, tying up ambulance resources. This delay increases risks for patients awaiting emergency care.
Earlier report
“Continuing average handover delays (and therefore response delays) which create a risk of future deaths. The averages conceal spikes of delayed handover and ambulance response times which increase the risk of mortality.”
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
6 months later
“Significant handover delays leading to ambulance resources being tied up at hospital with increased risk in mortality for patients in the community waiting for emergency ambulances.”
Same coroner as the earlier report.
Both reports identify handover delays at hospitals as a hazard that increases mortality risk. They link these delays to insufficient social care and patient flow problems.
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
9 months later
“Significant handover delays leading to ambulance resources being tied up at hospital with increased risk in mortality for patients in the community waiting for emergency ambulances.”
Both reports highlight ambulance handover delays at hospitals that tie up resources and increase mortality risk.
South West Yorkshire Partnership NHS Foundation Trust · NHS body
Insufficient mental health service engagement and follow-upEarlier report
“There were no attempts by mental health services to speak to [the deceased] directly to properly and adequately assess his mental health condition.”
The response stated
“The Trust will therefore develop and implement a triage checklist in respect of the review's findings.”
Raised again
1 year 10 months later
“there were only two attempts to see [the deceased] by the enhanced community mental health team between 28 November 2023, when she was seen in”
Both reports highlight insufficient attempts by mental health services to engage patients directly in order to assess their mental health condition. They differ in the number of attempts (none versus two) and the specific circumstances.
NHS England · National body
Shortage of autism-specific crisis care servicesEarlier report
“She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place)”
The response stated
“registered providers are required to ensure their staff receive specific training on learning disability and autism appropriate to their role”
Stated timescale: 1 July 2022
Raised again
2 years 11 months later
“there was a gap in the provision of care for individuals suffering with autism and in crisis”
Both reports highlight a lack of adequate care and support for autistic people experiencing crisis or mental health needs. The earlier report focuses on missing care coordination and care plans, while the later report notes a continuing gap in crisis provision for autistic individuals.