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
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 3 months later
“An ambulance resource arrived around 10 hours from [the deceased]'s first call (to 111 services), and 8 1⁄2 hours after the ambulance service categorised this as a call requiring attendance within 2 hours.”
Both reports highlight that excessive demand on the ambulance service leads to unacceptably long response times despite categorisation requiring rapid attendance.
Department of Health and Social Care · National body
Insufficient inpatient bed capacity leading to delayed discharges and patient harmEarlier report
“Lack of inpatient mental health beds and lack of Psychiatric decisions unit (PDU) spaces: The inquest heard how there was a regional and national lack of inpatient beds and spaces in PDU.”
The response stated
“Consideration is needed urgently to fund further mental health beds and PDU spaces to ensure patients are not kept unattended in extremely busy emergency departments.”
Raised again
1 year 11 months later
“There is a lack of inpatient beds leading to unacceptable wait times in A&E for those suffering with their mental health who are awaiting beds.”
Both reports highlight a shortage of inpatient mental health beds that forces patients to remain in emergency departments for extended periods. The core concern is the same: insufficient bed capacity leading to unsafe ED waits.
Department of Health and Social Care · National body
Insufficient inpatient bed capacity leading to delayed discharges and patient harmEarlier report
“The Matron in Acute and Urgent Care confirmed bed capacity remains an ongoing problem and has not been resolved.”
The response stated
“The Trust (SWLStG) fully acknowledges the concern regarding insufficient bed capacity in London and the reason why the Coroner has cause to raise these concerns.”
Raised again
6 months later
“There is a lack of inpatient beds leading to unacceptable wait times in A&E for those suffering with their mental health who are awaiting beds.”
Both reports identify a shortage of inpatient mental health beds causing prolonged waits for patients in emergency settings.
Department of Health and Social Care · National body
Insufficient inpatient bed capacity leading to delayed discharges and patient harmEarlier report
“had he needed admitting it is apparent no beds would have been available at Green Lane Hospital Devizes when an enquiry was made on 6 July 2014”
The response stated
“The Trust Board closely monitors bed pressures and out of area placements and is continually working with its Commissioners and NHS England to manage the situation optimally.”
Raised again
9 years 8 months later
“At the time of Tim's mental health crisis on the 2 February 2024, had the decision to admit him been possible, he still would not have been admitted as there were five other individuals in the queue before him also waiting for admission.”
Both reports highlight that a shortage of inpatient mental health beds prevented admission despite the patient's and family's request for hospitalization. The core issue is the unavailability of beds leading to denied care.
Department of Health and Social Care · National body
Insufficient inpatient bed capacity leading to delayed discharges and patient harmEarlier report
“Lack of inpatient mental health beds and lack of Psychiatric decisions unit (PDU) spaces: The inquest heard how there was a regional and national lack of inpatient beds and spaces in PDU.”
The response stated
“Consideration is needed urgently to fund further mental health beds and PDU spaces to ensure patients are not kept unattended in extremely busy emergency departments.”
Raised again
1 year 11 months later
“I am concerned of the continuing lack of Mental Health Unit inpatient beds in Suffolk, and more widely throughout England and Wales.”
Both reports highlight a shortage of inpatient mental health beds leading to unsafe situations for patients awaiting admission. The earlier report also mentions missing PDU spaces, while the later report focuses solely on the lack of Mental Health Unit beds.
Earlier report
“When a prisoner is on an ACCT (Assessment, Care in Custody and Teamwork) and a CSRA (Cell Sharing Risk Assessment) indicates an inmate should be in a cell alone for the protection of others.”
The response stated
“providing clear information for staff and prisoners about the ACCT process and their role in it”
Raised again
8 years 11 months later
“ACCT, there was little understanding of the requirement to complete or review the care plan and support actions at every ACCT review not just the planned reviews;”
Both reports highlight shortcomings in staff understanding and application of the ACCT review process, particularly regarding care plan completion and updates.
Department of Health and Social Care · National body
Insufficient social care provision leading to discharge delaysEarlier report
“The delay in his discharge via Adult Social Care meant that an acute hospital bed was not available to the Trust.”
The response stated
“a GM Discharge Pathway and good Discharge to Assess (D2A) system in place”
Raised again
4 years 4 months later
“That delay in discharge for patients ready to be discharged due to lack of suitable social care in the community is causing congestion in the hospital admission process”
Both reports identify delayed patient discharge caused by insufficient post‑hospital care placements as blocking acute beds.
Earlier report
“The medical care provided to service personnel through the DCMH is not truly independent, in that personal medical information may be disclosed to Chain of Command where substantial public interest demands disclosure”
The response stated
“case. I will address each area in turn. Disclosure of information between DCMH and the Chain of Command. DCMH operates as an independent organisation, which sits within Defence Primary Healthcare (DPHC), a Tri-Service organisation in UK Strategic Command. Although military DCMH staff2 are drawn from the medical services of the Royal Navy (RN), Army and Royal Air Force (RAF), DCMH is independent of all three Service chains of command. Mental health services play a vital Occupational Health role in”
Raised again
3 years later
“I was concerned to hear that when a risk management and safety plan has been prepared by the Defence mental health services the information contained about relevant protective factors and safety actions is not necessarily shared with the Chain of Command.”
Both reports highlight problems with how mental‑health information is handled between defence medical services and the Chain of Command. The earlier report warns that lack of independence leads to non‑disclosure fears, while the later report notes that protective‑factor information is not routinely shared with the Chain of Command.
Earlier report
“As to how that information is shared with other agencies involved in the care of that patient to ensure that it is accurately passed on, particularly as to the level of risk and degree of urgency.”
The response stated
“we are now updating leaflet 2-7-2 of the Department's medical policy document (Joint Service Publication (JSP) 950) which covers the provision and management of Defence mental health services. This will include new guidance and policy on the principles of transfer, which will include addressing both internal transfers of care between different Defence Medical Services (DMS) care providers and the transfers between DMS providers and external agencies.”
Raised again
9 years 9 months later
“The lack of detail contained within the case conference notes hindered this inquest's ability to establish precisely what risk information was shared.”
Both reports highlight problems with sharing and documenting risk-related information about armed forces personnel with mental health needs. The earlier report focuses on inter‑agency transmission of risk details, while the later report notes insufficient detail in case conference notes and VRM process documentation.
Earlier report
“no available evidence to suggest that [the deceased]'s age (87 years old), played a part in this tragic incident.”
The response stated
“The Civil Aviation Authority (CAA) has accepted the recommendations issued by the AAIB and has commenced work to address them. This includes a project to look at the current Pilot Medical Declaration (PMD) system and whether it is fit for purpose. As part of this, the CAA has committed to the following: 1. Updating the CAA's PMD webpage with supplementary information for pilots. This will also include a link to information on the UK Driver and Vehicle Licensing Agency (DVLA) website; 2. Updating”
Stated timescale: Q4 2023
Raised again
1 year 5 months later
“Drivers over 70 are required to apply for a new licence every 3 years and there is no requirement for there to be any form of medical check or assessment to confirm fitness to drive.”
Both reports highlight reliance on a self‑declaration system for people aged 70 and over without mandatory medical assessment or guidance. The earlier case concerns pilots’ medical declarations; the later case concerns drivers’ licence renewals.
Earlier report
“Records of calls handled were very brief and, at times, inaccurate.”
The response stated
“issued internal communications to all staff working on PIP and ESA early in March 2021 to reinforce the importance of recording notes on the appropriate computer systems and remind them that all colleagues are required to ensure that notes: a. are made following all interactions with customers or third parties where an accurate record of it is needed, and b. are an accurate and factual account of the conversation, including both any action agreed or taken, and the full reasons for decisions made”
Stated timescale: March 2021
Raised again
3 years 9 months later
“I am also concerned that the DWP currently has no ability to effectively audit its large payments caseload to ascertain whether the failure in record keeping evident in the present case has occurred in other cases.”
Both reports highlight inadequate record‑keeping of interactions with claimants, which hampers accurate decision‑making and oversight.
Earlier report
“The ability for UK users to purchase [REDACTED], through Amazon in the United States and to take delivery in the United Kingdom without effective border and/or custom controls.”
The response stated
“seeking to tackle at source the suppliers of harmful substances for the purposes of suicide”
Raised again
11 months later
“[REDACTED] can be purchased from abroad and imported to Great Britain with no restrictions;”
Both reports highlight that certain harmful substances can be bought from overseas and brought into the UK without adequate border or customs controls. The earlier report focuses on purchases via Amazon US, while the later report notes unrestricted import more generally.