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
“Timely access to Healthy Minds is also hindered by long waiting times.”
The response stated
“The CCG commissioned a new Primary Care Mental Health Pathway during 2016/17, which mobilised in May 2017. The model has been developed to respond to the local population needs, preparing service users to access therapy in order to optimise recovery performance. The service is subject to robust a performance dependent payment framework which provides assurance of performance delivery.”
Stated timescale: May 2017
Raised again
6 years 11 months later
“Another particular problem identified was the long waiting times for psychological assessment.”
Both reports highlight long waiting times as a barrier to receiving psychological services. The earlier report ties the delay to accessing Healthy Minds, while the later report notes long waits for psychological assessment more generally.
Department for Transport · National body
Young drivers carrying peer passengers increase collision riskEarlier report
“(5) 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 1 month later
“[the deceased] was aged 18 at the time of his death following the collision and had passed his driving test on 23 May 2023. This was 6 months and 16 days prior to the collision. At the time of the collision, he was legally carrying 3 other young persons, his friends.”
Both reports highlight that carrying passengers in a vehicle driven by a young or newly qualified driver increases the risk of death or injury. They identify the same hazard: passenger presence amplifying danger for inexperienced drivers.
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”
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
8 months later
“The lack of mental health/alcoholism/addiction support, treatment and therapy provided to veterans whilst they are:”
Both reports highlight insufficient mental health support for military personnel, covering service and post‑service periods. The later report expands the scope to include alcoholism/addiction and intensive training, but the core concern remains the same.
His Majesty's Prison and Probation Service · National body
Lack of basic first aid training and CPR among prison officersEarlier report
“It is not mandatory for prison officers to have basic first aid training (which includes the provision of CPR) which is in-date.”
The response stated
“Following evidence heard at the inquest, you have raised some concerns regarding the first aid training for staff, particularly in relation to the use of CPR. Thank you for bringing your concern to my attention. As you are aware, the HMPPS First Aid Policy Framework was re-issued nationally in August 2023. The revised policy highlights the training requirements for Emergency First Aid and First Aid in prisons, including the importance of Governors ensuring that there is an appropriate number of”
Stated timescale: August 2023
Raised again
8 months later
“Evidence was heard that after April 2024, basic first aid training (including CPR training) has been omitted from the foundation training programme for those training to be prison officers”
Both reports highlight that prison officers are not required to have up‑to‑date basic first aid/CPR training. The earlier report focuses on lapsed certification, while the later report notes the removal of such training from initial officer training.
His Majesty's Prison and Probation Service · National body
Lack of basic first aid training and CPR among prison officersEarlier report
“- (1) Some Prison staff had not received any cardiopulmonary resuscitation training. Either as part of initial training or any refresher training.”
The response stated
“The Governor at HMP New Hall has reviewed the band/grade and number of staff who need to be trained in first aid, and the number of such staff required on duty at times throughout the day. The prison currently has 40 staff trained in FAW and 48 in EFAW, and these numbers are considered to be sufficient to ensure that an appropriate response can be provided in any emergency situation that may arise at any time.”
Raised again
6 years later
“Evidence was heard that the majority of those prison officers who had commenced in their roles prior to 2018 had no first aid/basic life-saving skills and no ability/training in undertaking cardiopulmonary resuscitation ('CPR').”
Both reports highlight a lack of cardiopulmonary resuscitation (CPR) training among prison staff. The earlier report notes some staff had received none, while the later report finds a majority of pre‑2018 officers untrained and ongoing gaps in training.
His Majesty's Prison and Probation Service · National body
Lack of basic first aid training and CPR among prison officersEarlier report
“Action is required to ensure that Prison Officers and Staff with direct access to prisoners have basic first aid training, CPR training and familiarisation with the use of a defibrillator.”
The response stated
“all but two of the CMs at the prison have been trained, and those two members of staff will be provided with training as soon as they return to duty. HMP Coldingley also uses a monthly closedown of the prisoner regime to provide opportunities for training for the wider staff group and this includes instruction on CPR and on the use of defibrillators.”
Stated timescale: as soon as they return to duty
Raised again
9 years 7 months later
“Evidence was heard that after April 2024, basic first aid training (including CPR training) has been omitted from the foundation training programme for those training to be prison officers,”
Both reports highlight a lack of basic first aid and CPR training for prison officers. The earlier report calls for training existing staff, while the later report notes the omission of such training from new‑officer foundation programmes.
Norfolk and Suffolk NHS Foundation Trust · NHS body
Physical health check delays mental health referralsEarlier report
“On 25 February 2016 Mr [name redacted] was referred by a Social Worker at Herring House, where he was residing, to the Community Mental Health Team and he was given an appointment for 21 March 2016, under 4 weeks from the date of the initial referral.”
The response stated
“The service user will be given the phone number for the duty worker so if they experience change in their circumstance before attending their appointment they can speak to someone.”
Raised again
7 years 8 months later
“However, the court was told that an AMHP, despite their role in the coordination of the mental health assessment and admission to hospital of a patient, were not permitted to make direct referrals to the emergency Crisis Resolution and Home Treatment Team.”
Both reports highlight barriers in the referral pathway that delay or prevent timely access to the Crisis Resolution and Home Treatment Team. The earlier case shows excessive waiting times after referral; the later case shows a lack of authority to make direct referrals, causing a similar delay in crisis intervention.
Earlier report
“Mrs [name redacted] did not receive a comprehensive risk assessment prior to her discharge from the Home Treatment Team on the 25th April 2022.”
The response stated
“we attach a detailed action plan addressing the concerns raised by you.”
Raised again
1 year 6 months later
“The medical record documentation for Mr [name redacted] had significant omissions that included an incomplete risk assessment in February 2022 for Mr [name redacted]”
Both reports highlight a missing or incomplete risk assessment before a patient’s transition from the Home Treatment Team. The earlier case concerns discharge to GP care, while the later case concerns transfer after crisis intervention.
Earlier report
“Evidence heard at [the deceased]'s Inquest indicates that there is a strong relationship between the hours lost due to handover delays and the response times being delivered by SWAST.”
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
10 months later
“Continuing average handover delays (and therefore response delays) which create a risk of future deaths.”
Same coroner as the earlier report.
Both reports identify prolonged ambulance handover delays as the core problem affecting response times and patient safety. They describe how these delays increase risk of harm, though the later report adds detail about concealed spikes and broader system factors.
Greater Manchester Mental Health NHS Foundation Trust · NHS body
Fragmented mental health record keepingEarlier report
“The court heard evidence that the Trust's Psychological Therapy serviced used (and continues to use) a different computerised record-keeping system from that used by staff providing acute mental health services, which the latter staff group do not necessarily have access to”
The response stated
“the Trust has issued a Safety Alert to all GMMH staff to ensure they are aware to check whether a patient is open to another service within the Trust and that they know how to gain access to information to inform risk assessment and the formulation of care plans.”
Stated timescale: end of July 2022
Raised again
2 years 5 months later
“The means of communication is known and agreed between all mental health agencies to ensure all relevant patient information is held in an accessible central repository.”
Both reports highlight problems arising from fragmented mental‑health record keeping that prevent clinicians from accessing complete patient information.
Earlier report
“Mr [name redacted] was aged 72. The Community Mental Health Team advised on 18/10/18 that he required an immediate admission for inpatient mental health treatment for his own safety.”
The response stated
“NHS. England has committed to eliminating. the practice. of sending people out of-area for non-specialist acute inpatient:care due to”
Stated timescale: 2021
Raised again
5 years 7 months later
“Evidence given by the court appointed expert consultant psychiatrist was that Ms [name redacted] was not adequately medicalised and that she needed assessment and medical review with optimisation of treatment in a mental health hospital. Her response to treatment needed to be observed.”
Both reports highlight that a shortage of mental health inpatient beds prevents patients who need immediate admission from receiving appropriate hospital care. This leads to either no admission or placement in unsuitable settings.
Greater Manchester Integrated Care · Other
Delayed discharge due to insufficient social care placementsEarlier report
“The evidence was that speedier discharges would occur if there was improved availability of social care”
Raised again
1 year 2 months later
“Mr [name redacted] was assessed as being suitable for discharge on 18th December. He remained in an acute hospital setting for a further 4 weeks due to challenges in identifying a suitable care home.”
Same coroner as the earlier report.
Both reports highlight delayed patient discharge caused by insufficient availability of appropriate social care or suitable care‑home placements. The core issue is the lack of timely community support leading to prolonged hospital stays.