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
“The UK Border Force do not have the legal powers to seize a consignment of [REDACTED] because it is not a prohibited poison under the Poisons Act 1972.”
The response stated
“In June 2023, wrote to all Chief Constables, highlighting the need for preparedness in addressing related challenges. Briefing materials were circulated to all UK police and regional suicide prevention leads.”
Stated timescale: June 2023
Raised again
7 months later
“There are no restrictions on the import of [REDACTED] from abroad.”
Both reports highlight that current legal frameworks do not allow authorities to prevent or intercept shipments of the specified substance that could be used for self‑harm. They note the absence of powers to seize, detain, or restrict imports of the substance.
Earlier report
“Yorkshire Ambulance Service were unable to respond to [the deceased]'s call until 2 hours and 26 minutes had passed.”
The response stated
“Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25.”
Stated timescale: 2024/25
Raised again
1 year 3 months later
“notwithstanding the national target for Category 3 999 calls of 9 out of 10 responses within 120 minutes, the anticipated wait for a Category 3 ambulance on 1st June 2024 was around 3 hours and 15 minutes.”
Both reports highlight that ambulance services are failing to meet national response‑time targets, leading to dangerously long waits for patients.
Earlier report
“I heard evidence that NWAS failed to meet target times which are nationally set by the Department of Health”
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 2 months later
“The court heard evidence to the effect that, notwithstanding the national target for Category 3 999 calls of 9 out of 10 responses within 120 minutes, the anticipated wait for a Category 3 ambulance on 1st June 2024 was around 3 hours and 15 minutes.”
Both reports highlight that national ambulance response time targets are not being met. They describe systemic failures leading to delayed ambulance arrivals despite set performance standards.
National Institute for Health and Care Excellence · National body
Insufficient anticoagulation guidance for immobilised patientsEarlier report
“guidance for clinicians in relation to reducing the risk of DVT when dealing with patients such as Ms [name redacted] who are young and on oral contraception but are immobile following an accident and require surgery is unclear”
The response stated
“We will request these be addressed as soon as possible”
Stated timescale: as soon as possible
Raised again
1 year 6 months later
“there was no national guidance that would assist clinicians in primary care in assessing whether they should consider prolonging the course of anti- coagulation prescribed in secondary care to reduce the ongoing risk of elderly immobile patients such as Mrs [name redacted] developing a fatal DVT in the community”
Same coroner as the earlier report.
Both reports highlight insufficient clinical guidance regarding anticoagulation management to prevent deep vein thrombosis in immobilised patients.
NHS England · National body
Lack of GP awareness of prescribed medicationEarlier report
“There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed”
The response stated
“The Department is working with other healthcare regulators including the General Medical Council and their equivalents in Scotland, Wales and Northern Ireland in the area of digital healthcare provision. As a result, a review of the UK's legislative position was undertaken and gaps identified. These included cases involving inappropriate prescribing and a lack of checks with the patient's GP before prescribing.”
Raised again
3 years later
“The delay of information relating to what has been prescribed to an individual being sent to the GP surgery by voluntary and NHS organisations.”
Both reports highlight problems with ensuring that a patient's GP receives timely information about prescribed medicines. The earlier report notes a lack of any requirement to inform the GP, while the later report points to delays in sending that information.
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”
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 6 months later
“Despite these steps there remain insufficient beds available to meet patient need.”
Both reports highlight a shortage of inpatient psychiatric beds that prevents timely admission of suicidal patients. The later report notes ongoing bed shortages despite trust initiatives.
Earlier report
“The trust's clinical records were of a particularly poor standard which impeded the Trust's governance investigation and the inquest investigation in determining what, if any consideration was given to the possibility that Mr [name redacted] was suffering from an infection.”
The response stated
“An Internal Alert has been shared with staff via email, Alert reference Issued Date 9 November 2023 which details good record keeping standards that should be adhered to by all staff.”
Stated timescale: 9 November 2023
Raised again
1 year later
“The investigation of this inquest was prejudiced by the absence of contemporary nursing and medical notes from various stages of [the deceased]'s treatment.”
Same coroner as the earlier report.
Both reports highlight deficiencies in the Trust's clinical documentation that hinder investigations and decision‑making.
Home Office · National body
Lack of formal procedure for informing the Home Office when a detainee is placed on ACDTEarlier report
“they had received training and were told not to make a report under Rule 35(2) of the Detention Centre Rules (SI 2001/238) but instead to use the ACDT procedures to monitor suicidal tendencies.”
The response stated
“The Home Office will take steps to ensure that all staff working in IRCs are reminded of the guidance in place, and of their information sharing responsibilities. This will ensure that information on detainees at risk of suicide and self-harm who are being managed under ACDT procedures is shared promptly and appropriately with all relevant parties. The Director of Detention and Escorting Services will write to all parties in IRCs by the end of April 2019 to bring the requirements for sharing information”
Stated timescale: end of April 2019
Raised again
5 years 8 months later
“Despite [the deceased] being witnessed as having made an attempt to take his life, and self- reporting a further attempt during his detention, no R35 report was made.”
Both reports concern failures to make required Rule 35(2) reports for detainees with suicidal intentions. The earlier issue was training that discouraged reporting, while the later issue shows a gap between expectation and practice leading to missing reports.
Earlier report
“There were multiple failures in the days leading up to Ms [name redacted] death. During the evidence it was made clear that a mistake was made in relation to closing a missing person investigation”
The response stated
“The MPS has invested significantly in safeguarding focused police officer posts as part of the new BCU model, which has resulted in an increase of dedicated MPU officers.”
Raised again
5 years 9 months later
“if Mr [name redacted] had been reported missing at the time he was in Charing Cross police station then there would have been more that officers could have done to keep him safe;”
Both reports highlight shortcomings in how the Metropolitan Police handles missing or vulnerable persons, pointing to gaps in procedure and resourcing.
Welsh Ambulance Service NHS Trust · Ambulance service
Ambulance handover delays due to bed shortagesEarlier report
“handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital.”
The response stated
“these, we have agreed some additional measures that we will be implementing in January 2024. These measures are expected to reduce the number of conveyances to The Grange Hospital through direct admission to alternative sites and the introduction of a new temporary facility that can be used for patients who are often those that experience the longest delay in handover.”
Stated timescale: January 2024
Raised again
11 months later
“the reason given for the significant delay to respond to the call was ambulances waiting at Emergency Departments to hand over patients, meaning that the ambulances are not therefore responding to calls for assistance.”
Both reports identify ambulance handover delays at emergency departments as causing ambulances to be unavailable for new emergency calls, thereby increasing response times and risking patient safety.
Welsh Ambulance Service NHS Trust · Ambulance service
Ambulance handover delays due to bed shortagesEarlier report
“unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”
The response stated
“In October 2015 WAST introduced a new clinical response model to implement new ways in which callers to 999 are assessed. This sought to ensure that patients and users of the service received the most appropriate care and a response to suit their individual needs. The changes made clearly identify those patients who require an immediate life-saving response and these patients receive the highest priority response in the fastest possible time. foe) All other patients receive a bespoke”
Stated timescale: October 2015
Raised again
7 years 5 months later
“ambulances waiting at Emergency Departments to hand over patients, meaning that the ambulances are not therefore responding to calls for assistance”
Both reports describe ambulances being delayed while waiting to hand over patients at emergency departments, making the vehicles unavailable for other emergency calls.
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
6 months later
“The Trust had over 200 outstanding incidents, of which 31 were other Category 2 cases, and 50% of their vehicles were being delayed at hospitals within the region for anything between 189 minutes and 441 minutes.”
Both reports identify hospital handover delays as compromising ambulance availability and extending response times. They describe the same mechanism whereby delays at hospitals prevent ambulances from meeting response targets.