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
“During the course of the inquest, the evidence revealed concerns with the implications of the evidence of three witnesses employed by NHS Professionals at times when the deceased was already dead.”
The response stated
“| have passed your report regarding the two registered nurses to our Fitness to Practise team for further investigation; we have now also received a formal referral from NHS Professionals in respect of these two nurses. The case of the two nurses is now with our screening team and they will use the information we have received from your office and NHS Professionals to consider the matter further.”
Raised again
5 years later
“(1) To Westmorland Court. The General Practitioner who came to give evidence said that care had improved since Reg's death but he still had concerns about care given and had to visit regularly every week to check residents -the only one of six homes he covers that requires this level of support. He said it was a struggle to provide good quality care and felt this report would be helpful -as I stated at inquest it is not intended in any way to be punitive but to put focus on areas that may be im”
Both reports highlight concerns that nursing staff produced inaccurate records or observations about patients who were already deceased or unavailable, undermining the reliability of clinical documentation.
Department of Health and Social Care · National body
Unrestricted online purchase of lethal prescription medicationEarlier report
“- is available to be purchased in lethal quantities from a UK website for less than £5:00, again without restriction.”
The response stated
“I am advised that suicide prevention policy leads in the health system, at the Department of Health and Social Care, Public Health England (PHE), and NHS England and NHS Improvement (NHSEI), are alert to the risk posed by websites promoting suicide methods, and their direction on the use of certain chemicals in completing suicide, including the substance taken by Mrs [name redacted]. These organisations, along with key stakeholders and academics, are looking at what data is available on suicides by this”
Raised again
3 years 7 months later
“The substance is readily available to purchase online without the need for any explanation of the purchaser's intended use for the substance”
Both reports highlight that the substance can be bought online without restriction, enabling lethal self‑harm. The core concern is the unrestricted availability facilitating suicide.
Earlier report
21 Jan 2022
Anthony Walgate, Gabriel Kovari, Daniel Whitworth and Jack Taylor↗Coroner HH Judge Munro QC
“First, lack of professional curiosity. This is a phrase which has been used to try and capture what lay at the root of many of the individual errors and oversights.”
The response stated
“the MPS will embed these changes across the whole organisation by 30th June 2022.”
Stated timescale: 30th June 2022
Raised again
2 years 6 months later
“(6) There was a lack of professional curiosity and a lack of sufficient probing into information relevant to risk.”
Both reports identify a lack of professional curiosity as a contributing factor. The later report adds that this also involves insufficient probing into risk-related information.
Department of Health and Social Care · National body
Lack of personal care and health deterioration in domiciliary careEarlier report
“Since 2020 Ms [name redacted] had been provided with domiciliary care commissioned by the local authority. At the time of her death twice daily visits were undertaken. Ms [name redacted] was utilising state funded domiciliary care visits to deliver fast food to her home, no personal care was being provided.”
The response stated
“Review, revise and disseminate the risk escalation process with health and social care staff.”
Raised again
11 months later
“Poor standards of communication between the domiciliary care company, the local authority and NHS trust resulted in a failure to identify the deterioration in Mr [name redacted] living conditions and health.”
Same coroner as the earlier report.
Both reports highlight that domiciliary care funded by the state was being used for non‑care purposes (food delivery or pub/café trips) instead of providing personal care. They also point to inadequate communication and oversight between care providers, commissioners and NHS services as a contributing factor.
NHS England · National body
Unrecognised oesophageal intubation and unconfirmed tracheal tube placementEarlier report
“During the course of evidence | heard that an (admitted)”
The response stated
“All members of the anaesthetic department at Hinchingbrooke are to participate in an airway simulation course at a high fidelity simulation centre. We have identified a suitable course and are in the process of planning training with the course provider.”
Stated timescale: by the end of March 2018
Raised again
6 years 8 months later
“(1) I have been told that capnography is the only reliable test, the gold standard, to confirm that a tracheal tube is in the right place, that no other test should override it.”
Both reports highlight that reliance on capnography is essential to detect oesophageal intubation and that a misunderstanding of its significance can lead to missed esophageal placement.
Earlier report
“There is no definitive guidance provided to the industry in relation to the stacking or unstacking of bales, or in relation to the loading and strapping of loaded trailers”
The response stated
“We continue to monitor and adapt our guidance in light of incidents and modern farming practices. For example, INDG125(rev3) was revised in 2012 to provide updated guidance to the industry on safe working practices, including the safe loading and unloading of bales.”
Raised again
4 years 3 months later
“It became apparent that there were no clear images in the guidance or support materials produced by HSE to assist drivers who load and unload bales.”
Both reports address insufficient visual guidance for safe bale handling during loading/unloading. The earlier report cites lack of definitive written guidance; the later notes missing clear images in existing guidance.
Earlier report
“Yorkshire Ambulance Service were unable to respond to [the deceased]'s call until 2 hours and 26 minutes had passed. Yorkshire Ambulance Service were on their highest level of escalation at that time with significant delays at hospital handover caused or contributed to the delay in an ambulance being available to [the deceased].”
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
11 months later
“Specifically, I was told that the response standards for both Category 1 and Category 2 calls (for the year to date), whilst improved from the time of Mr [name redacted] death, still remain outside of the target response standards (both on average and at the 90th centile).”
Both reports highlight that delays in hospital handover of patients cause ambulances to remain unavailable, leading to prolonged response times for emergency calls.
NHS England · National body
Missing mental health hand‑over in custodyEarlier report
“She stated that if she had been aware that he was open to the HTT she would have sought information about his involvement”
The response stated
“implementing a documented and recognised system within our bed management team for all such calls which includes phonetic spelling and other controls to ensure a consistent approach to this matter”
Stated timescale: late September 2019
Raised again
5 years later
“Lack of effective documentation and communication between the Liaison Diversion Service (LDS) and the police within the custody suite.”
Both reports highlight failures in communicating mental health information between liaison services and police in custody settings. The earlier case concerns missing patient history hand‑over, while the later case notes absent documentation and communication between the Liaison Diversion Service and police.
Department of Health and Social Care · National body
Inadequate clinical records hinder investigationsEarlier report
“The trust's clinical records were of a particularly poor standard which impeded the Trust's governance investigation and the inquest investigation”
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
8 months later
“During Mr [name redacted] ward-based treatment on 3 & 4th May 2022 clinical records were either of a poor standard or were non-existent. The absence of clear records impeded the effective investigation”
Same coroner as the earlier report.
Both reports highlight that poor-quality or missing clinical records hindered investigations into patient deaths.
Earlier report
“Clinical records were poorly maintained , resulting in an unclear picture of fluid administration.”
The response stated
“Cross site audits have been completed on COTE (Care of the Elderly) wards on a random basis to understand a cross section of compliance with fluid management with no notice given to the ward in advance of the audit. The audits capture patients who are on fluid restriction, patients requiring oral and intravenous hydration, parenteral nutrition and output monitoring, whether the intake and output is entered on Careflow Vitals and appropriate action taken as necessary. The audits were completed by”
Stated timescale: completed
Raised again
1 year 5 months later
“During Mr [name redacted] ward-based treatment on 3 & 4th May 2022 clinical records were either of a poor standard or were non-existent.”
Same coroner as the earlier report.
Both reports highlight problems with inadequate clinical record‑keeping that obscured patient care details. The earlier case concerned fluid balance documentation; the later case concerned overall record quality hindering death investigation.
Earlier report
“Clinical records were poorly maintained, exacerbating the lapses in communication between those treating Mr [name redacted].”
The response stated
“has completed all the actions assigned to the department within the Trust's SI recommendations and subsequent Action Plan. If any scan is mis- reported, the Department uses it as a learning opportunity, and it is reviewed at the Departmental Radiology Event and Learning Meeting (REALM) and undertakes a process of peer review. The Radiology Department has reviewed Mr [name redacted] scans through its Governance process.”
Raised again
1 year 8 months later
“During Mr [name redacted] ward-based treatment on 3 & 4th May 2022 clinical records were either of a poor standard or were non-existent.”
Same coroner as the earlier report.
Both reports highlight problems with the quality of clinical records. The earlier report links poor record‑keeping to communication lapses, while the later report links it to impeded investigations.
Earlier report
“Yorkshire Ambulance Service were on their highest level of escalation at that time with significant delays at hospital handover caused or contributed to the delay in an ambulance being available to [the deceased].”
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
11 months later
“They had entered a sustained period where demand was outstripping the resources they had available. This was worsened by the fact that what resources they did have were being delayed at hospitals due to lengthy hospital handovers at the Accident and Emergency departments.”
Both reports highlight that delays in ambulance handovers at emergency departments reduce ambulance availability and worsen response times. The core concern is the impact of hospital handover bottlenecks on timely ambulance response.