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 · Other
Delayed discharge due to insufficient social care placementsEarlier report
“The inquest heard evidence that the acute hospital setting was difficult for Mr [name redacted] due to his dementia and created risks to his health once he was medically optimised. He had to remain there due to a lack of suitable care/nursing beds.”
The response stated
“1. Home Finders Team (as described above) that are focussed specifically on supporting timely and appropriate placements for patients ready for discharge.”
Raised again
11 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 that patients remained in acute hospital beds because suitable care/nursing placements were unavailable, causing delayed discharge and blocking acute beds for others.
Department of Health and Social Care · National body
Delayed discharge due to lack of suitable care home placementEarlier report
“The inquest heard that Mr [name redacted] could have been discharged from 19th September when he was medically optimised. However he remained in an acute hospital setting until his death on 22nd 1 October because of the challenges of finding a suitable EMI placement for him.”
The response stated
“a GM Discharge Pathway and good Discharge to Assess (D2A) system in place”
Raised again
4 years 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 describe delays in discharging patients from acute hospitals because suitable post‑acute placements could not be found. The core issue is the shortage of appropriate care settings leading to prolonged acute stays.
Department of Health and Social Care · National body
Insufficient social care provision leading to discharge delaysEarlier report
“The root cause for ambulance delays was found to be the lack of social care provision in Cornwall, whether care packages or beds in care homes.”
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
“There is a direct connection between the risk of excessive ambulance delays and inadequate social care provision, community hospital provision and primary healthcare support for discharges in Cornwall.”
Same coroner as the earlier report.
Both reports identify insufficient social care provision in Cornwall as the root cause of ambulance handover and response delays. They describe how this leads to delayed discharges, emergency department crowding, and consequent ambulance delays.
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
10 months later
“handover delays at the Royal Berkshire Hospital and the Wexham Park Hospital were found to be a substantial root cause of the problem (due to ambulance staff being delayed at hospital with patients who could not be admitted to Accident & Emergency as other patients were unable to be admitted to the wards until beds were available)”
Both reports identify ambulance handover delays at hospitals as a key factor causing prolonged ambulance response times. The earlier report concerns delays at Treliske and Derriford hospitals in Cornwall, while the later report concerns delays at Royal Berkshire and Wexham Park hospitals in Berkshire.
Earlier report
“- In relation to the Police, specific training with regards to risk assessments for mental health patients was lacking”
The response stated
“The Force's Missing Person Policy (MPP) is currently under review. The existing MPP, a policy jointly produced with NHS partners, is a comprehensive document setting out the way in which risk can be assessed and appropriate levels of responsibility: e the risk assessment process to identify whether people missing from mental health and medical care establishments should be categorised as being low, medium or high risk as identified by certain criteria; and e the responsibility for identified enq”
Stated timescale: January 2015
Raised again
9 years 10 months later
“(1) Cogent information about Ms [name redacted] declining mental health was provided repeatedly to Surrey and Borders Partnership secondary mental health teams from the refuge support workers. It was not explored with them, and insufficient weight was given to”
Both reports highlight failures in assessing mental health risk: the earlier cites lack of training for risk assessments, the later notes that clear information about declining mental health was not explored or weighted in triage.
Care Quality Commission · National body
Inaccurate and inconsistent care plan entries and record keepingEarlier report
“(1) The record keeping was inconsistent and lacked detail on general wellbeing.”
The response stated
“The provider has indicated they have also reviewed the quality of their own documentation and care records. In relation to food records, in addition to improved documentation, staff have also received additional training.”
Raised again
3 years 2 months later
“Overall documentation at the home was limited and lacked detail”
Both reports highlight inadequate documentation that fails to capture residents' wellbeing and nutrition needs. This shortcoming delays recognition of deterioration and risks to health.
Care Quality Commission · National body
Inaccurate and inconsistent care plan entries and record keepingEarlier report
“The documentation available at the inquest from the home was limited in detail. As a result, it was difficult to understand what observations had been undertaken by care home staff who were monitoring him.”
The response stated
“The Care Home confirmed that; 1. The Provider/Registered Manager is speaking to staff individually to reiterate the need for thorough record keeping in relation to falls but also generally. A documentation awareness training offer has been made to the Provider/Registered Manager by Tameside and Glossop CCG Quality Improvement Team. This has been accepted and sessions will take place in February via Microsoft Teams. The Local Authority require all providers to comply with good record keeping”
Stated timescale: February
Raised again
3 years 9 months later
“Overall documentation at the home was limited and lacked detail”
Same coroner as the earlier report.
Both reports highlight that the care home's documentation was limited and lacked detail, making it hard to assess care provided. The core issue is inadequate record‑keeping.
National Highways · National body
Drivers entering slip road wrong direction due to inadequate signageEarlier report
“Following the collision, large temporary No Entry signs were positioned at the slip road junction. They were quickly removed apparently because the original signs were deemed to comply with necessary regulations.”
The response stated
“Further temporary signing has been put in place at the exit point of the A5 off slip at the Little Brickhill junction in the form of two large 1200mm 'No Entry' signs on A-frames on each side of the carriageway (Traffic Signs Regulations and General Directions (TSRGD), Diagram 616 No entry for vehicular traffic). These signs are intended to provide mitigation against further wrong way driving incidents while a full safety review of the junction has been undertaken.”
Raised again
8 months later
“National Highways undertook a number of immediate remedial measures to try to prevent drivers turning and travelling the wrong way down this slip road, including narrowing the”
Same coroner as the earlier report.
Both reports address the hazard of drivers mistakenly entering the slip road in the wrong direction due to inadequate warning/signage. The later report adds physical narrowing and satnav‑voice concerns but the core unsafe condition remains the same.
Earlier report
“At no time during the two periods of Ms [name redacted] inpatient care was she assessed for venous thromboembolism (VTE) risk in contravention of trust policy.”
The response stated
“A VTE Screening and Assessment Clinical Alert was disseminated across the Trust”
Raised again
1 year 7 months later
“As per Physical Healthcare Policy, v.14.1, Feb 2021, 7.6, all patients should have a VTE risk assessment form completed and a VTE assessment on admission to the in-patient unit.”
Both reports highlight that patients were not receiving the required venous thromboembolism (VTE) risk assessment during inpatient care. The later report notes that the VTE assessment policy has not been fully embedded, leaving the same hazard unresolved.
Earlier report
“No review of the decision to discharge was sought or conducted when it became apparent that there had been a material change in [the deceased]'s presentation on the 10th November.”
The response stated
“The discharge assessment document is prepared prior to planned discharges and is then completed on the day of discharge by the discharge nurse. The final page of this document is the 'Discharge Plan' which contains the emergency contact numbers and a crisis contingency plan. A copy of this is handed to the patient upon discharge.”
Raised again
8 years 5 months later
“A discharge clinical entry and discharge risk assessment was not completed and there was no evidence of crisis information having been provided.”
Both reports highlight failures in the discharge process where essential documentation or review was omitted. They differ in focus: the earlier case stresses lack of a clinical review when the patient’s condition changed, while the later case notes missing discharge clinical entry, risk assessment, and crisis information.
Earlier report
“The Discharge Letter that was sent to Mr [name redacted] GP on 6 February 2019 was prepared by a doctor who had little involvement in his care and was not counter-checked by a senior clinician.”
The response stated
“The Clinical Director for the Borough has established process that ensures: - All new medical trainees receive a presentation regarding the standards expected and process of writing admission/discharge summaries. - During their first month working on the wards all new trainees have their written admission/discharge summaries checked and discussed at the ward round held prior to discharge of the patient. A senior doctor checks the documentation.”
Raised again
3 years 10 months later
“A discharge clinical entry and discharge risk assessment was not completed and there was no evidence of crisis information having been provided.”
Both reports highlight failures in the discharge process where critical risk information was omitted or not documented. The earlier case concerned missing details in discharge summary letters; the later case concerned absent discharge clinical entries and risk assessments.
HMP Swaleside · Prison or detention
Welfare checks missed and undocumentedEarlier report
“That measures put in place following Mr. [name redacted] death to ensure welfare checks are conducted are not overlooked”
The response stated
“HMP Swaleside has introduced a welfare check that staff conduct at approximately 8am. Staff must open the cell door and ensure they gain a verbal response from the occupant so they can assure themselves of the prisoner's wellbeing. The completion of the check must be recorded in the wing assurance book.”
Stated timescale: approximately 8am
Raised again
2 years 6 months later
“(2) It was clear from CCTV evidence that prison officers and operational support group officers were not conducting roll call welfare checks and other welfare checks in line with national guidance or local policies”
Same coroner as the earlier report.
Both reports highlight failures in ensuring that welfare checks are properly carried out and recorded. The earlier report focuses on checks being overlooked and undocumented, while the later report shows officers not performing the checks as required.