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.
563 links
His Majesty's Prison and Probation Service · National body
Recurring hazard (see the quoted concerns)Earlier report
“It is suggested that receiving HMPS staff should ensure that they read and consider the ACCT file with particular emphasis on the assessment of risk of self-harm and suicide”
The response stated
“NHSEI Health and Justice Quality Leads are required to approve the identification and selection of appropriately skilled and suitable individuals by the service provider.”
Raised again
5 years 2 months later
“a failure by prison and healthcare staff to read the incoming prisoner's core file. This hard copy file contains valuable information such as previous ACCT documents and SASH warning forms”
Both reports highlight the failure of prison and healthcare staff to read and act upon the prisoner's ACCT/core file containing self‑harm and suicide risk information. The earlier report stresses reading the ACCT file on arrival, while the later report notes that the core file with ACCT documents was not reviewed.
Earlier report
“support for service personnel with severe PTSD such as Mr [name redacted] whilst they were still serving and following discharge was patchy, difficult to access and did not appear to recognise how significant the impact of events they had witnessed”
The response stated
“I have asked the Head of the Defence Inquests Unit (DIU) to provide you separately with the details of the support Mr [name redacted] did receive.”
Raised again
1 year later
“there appears to have been no inquiry or check as to possible correlation with potential PTSD or other reasons for the behaviour, such as a lack of effective post- tour decompression”
Both reports highlight inadequate identification and support for service personnel suffering from PTSD after deployment. They differ in focus: the earlier concerns general patchy mental health support, while the later concerns missing inquiries into drug use and lack of discharge assessments.
Earlier report
“availability of ambulance crews is continuing to be compromised by delays at hospitals resulting in delays in response times which creates a risk to the life”
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
9 months later
“The delay in an ambulance attending patients due to the unavailability of ambulances.”
Both reports describe ambulance crew availability being reduced by delays in hospital handovers, which leads to longer response times and risk to patients. The later report adds that social‑care backlogs exacerbate the handover delays, but the core hazard remains the same.
Earlier report
“The ambulance delay in [the deceased]'s case, on 10 to 11 July 2022, was due to the demand on the service and delays in the patient handover process at the two main hospitals servicing Cornwall: Treliske (Royal Cornwall Hospital Trust in Truro) and Derriford (University Hospitals Plymouth Trust).”
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 2 months later
“The delay in an ambulance attending patients due to the unavailability of ambulances. This delay being significantly contributed to by the handover delays in hospitals. A significant factor contributing to the handover delays in hospitals being the backlog of patients who are fit for discharge but awaiting social care packages. Overall, this entails a lack of staff and room for those patients who are brought in via ambulance thus requiring ambulance crews to remain on hospital premises reducing”
Both reports identify ambulance delays caused by prolonged patient handover times at hospitals. The later report adds that handover delays are driven by a backlog of patients awaiting social care, while the earlier report focuses on overall demand and handover process delays.
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
7 months later
“The delay in an ambulance attending patients due to the unavailability of ambulances.”
Both reports identify ambulance handover delays at hospitals as reducing ambulance availability and increasing risk to patients. The later report adds that discharge backlogs exacerbate the handover problem, but the core hazard remains the same.
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 8 months later
“This delay being significantly contributed to by the handover delays in hospitals.”
Both reports identify ambulance crew delays during hospital hand‑over as a cause of reduced ambulance availability.
Department for Transport · National body
Young drivers carrying peer passengers increase collision riskEarlier report
“The carrying of passengers in the car increases the likelihood of death or injury not only to the driver but also to the passengers being carried, therefore multiplies the risk.”
The response stated
“the Department has decided to use the introduction of GDL in Northern Ireland as a pilot, to gather evidence on the potential for GDL in Great Britain.”
Raised again
6 years 4 months later
“Young drivers may be more likely to be involved in a collision with similar aged passengers in the car.”
Both reports highlight that carrying passengers increases the risk of death or injury for young, inexperienced drivers. They describe the same hazard—passenger presence amplifying crash likelihood—though the later report frames it as a collision likelihood.
Department for Transport · National body
Young drivers carrying peer passengers increase collision riskEarlier report
“The carrying of passengers in the car increases the likelihood of death or injury not only to the driver but also to the passengers being carried, therefore multiplies the risk.”
The response stated
“the Department has decided to use the introduction of GDL in Northern Ireland as a pilot, to gather evidence on the potential for GDL in Great Britain.”
Raised again
6 years 4 months later
“Currently there are no legal restrictions upon the licences of young and /or newly qualified drivers and the current vehicle licensing regime permits the carrying of young persons as passengers in circumstances such as these”
Both reports highlight that allowing young or newly qualified drivers to carry passengers increases the risk of death or injury. The earlier report focuses on the multiplied risk due to inexperience and distraction, while the later report notes the absence of legal restrictions that permits such passenger carrying.
Department for Transport · National body
Young drivers carrying peer passengers increase collision riskEarlier report
“As set out above, the court found that it was possible that the fact that [the deceased] had only just passed his driving test contributed to the collision.”
The response stated
“We will be considering policies relating to young, new drivers during this development.”
Raised again
8 months later
“Currently there are no legal restrictions upon the licences of young and /or newly qualified drivers and the current vehicle licensing regime permits the carrying of young persons as passengers in circumstances such as these”
Both reports highlight the absence of legal restrictions that would limit young or newly qualified drivers from carrying young passengers as a safety concern. They differ in that the earlier report also mentions possible time‑of‑day restrictions, while the later report focuses solely on passenger carriage.
Department for Transport · National body
Young drivers carrying peer passengers increase collision riskEarlier report
“As set out above, the court found that it was possible that the fact that [the deceased] had only just passed his driving test contributed to the collision.”
The response stated
“We will be considering policies relating to young, new drivers during this development.”
Raised again
8 months later
“Young drivers may be more likely to be involved in a collision with similar aged passengers in the car.”
Both reports highlight the increased collision risk posed by young, newly qualified drivers carrying peers as passengers. They call for reviewing or introducing restrictions to mitigate this specific hazard.
Medicines and Healthcare products Regulatory Agency · National body
Inadequate communication of SSRI suicide riskEarlier report
“However, it has been suggested that the "Black Box Warning" (as developed by the Food and Drug Administration in the USA) would have a more 1 immediate impact and capture some patient's attention highlighting any risks.”
Raised again
4 years 1 month later
“Whether there is adequate communication of the risks of suicide associated with the selective serotonin reuptake inhibitor (SSRI) medications, and”
Both reports highlight insufficient communication about suicide risk linked to SSRIs.
Earlier report
“He was climbing with no safety line He was not wearing a lifejacket or buoyancy aid He was not wearing clothing that offered no warmth in the water”
The response stated
“The RYA will be highlighting this safety information to its members through various electronic communications in the early part of this year, as well as in the RYA's annual Safety Advisory Notice.”
Stated timescale: early part of this year
Raised again
8 years later
“Further, I have a concern that personal floatation devices, such as lifejackets or buoyance aids are not legally required to be carried on all vessels, nor is there any legal requirement to wear lifejackets.”
Both reports identify the absence of lifejackets or buoyancy aids as a contributing factor to potential drowning deaths. The earlier case involves an individual climbing over deep water without a lifejacket, while the later case highlights a regulatory gap that leaves pleasure vessels without mandatory lifejacket carriage or wear.