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
“No warnings were given in the welcome information/briefing about the challenge the sea around the coast in Malta could present to a weak swimmer”
The response stated
“In July 2022, the Travel Advice read: Swimming During the summer, many beaches are patrolled by lifeguards and operate flag safety systems. You should make sure you understand the system and follow any warnings; red flags indicate dangerous or hazardous conditions. You should swim within designated swimming zones and take extra care if there are no life-guards, flags or signs. Follow local advice if jellyfish are present. You can find more information and a general code of conduct for beaches in”
Stated timescale: July 2022
Raised again
9 months later
“It was understood that the Greek Coroner had informed bereaved family members that the sea was particularly rough in Rethymno, Crete and had no lifeguards on duty between 31 August and the end of the summer season”
Both reports highlight a lack of adequate warnings or safety markers for sea swimming that puts weak or inexperienced swimmers at risk. The earlier case concerns missing briefing warnings in Malta, while the later case notes absent lifeguards and warning flags in Greece.
Greater Manchester Integrated Care · Other
Delayed trans-oesophageal echocardiogram availability and staffingEarlier report
“The use of different systems and reliance on postal services and lack of a clear, effective electronic system of referrals including transfer of images /notes meant there were delays in assessing patients”
The response stated
“We are looking at how we can bring the benefits of this type of technology to other services.”
Stated timescale: October 2023
Raised again
11 months later
“significant wait times for essential tests such as trans oesophageal echocardiograms to be carried out due to a shortage of suitably quailed professionals”
Same coroner as the earlier report.
Both reports highlight delays in obtaining trans‑oesophageal echocardiograms that hinder timely cardiac assessment and treatment planning. The earlier report stresses poor information sharing and referral processes, while the later report adds a shortage of qualified staff and ongoing communication barriers.
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 5 months later
“[the deceased] was subject to cellular confinement on a residential prison wing. 'Normal' or 'standard' cells may not be best for cellular confinement, particularly for a prisoner placed on an ACCT and therefore deemed at risk and vulnerable, due to cell environment and ligature points and less ability to check and observe by prison staff.”
Both reports highlight concerns about placing prisoners under ACCT in standard prison cells that may be unsafe due to ligature points and limited observation.
NHS England · National body
Incomplete paperwork and missing responsible clinician for section 5(2) holdsEarlier report
“There was a failure at Hull Royal Infirmary to understand the process of implementing Section 5(2) of the Mental Health act 1983 [MHA] (Doctors Holding Power) as well as general uncertainty about its significance and effect.”
The response stated
“I am therefore taking steps to raise this issue with HSC Trust Chief Executives and relevant professional bodies, in order to ensure that the appropriate action is taken to address this point.”
Raised again
1 year 6 months later
“Patients admitted onto a ward at the acute Trust detained under various sections of the Mental Health Act have an allocated Responsible Clinician. As section 5 (2) is a holding power only, there is no Responsible Clinician allocated for a vulnerable patient being held pending assessment for consideration for detention under the Mental health Act.”
Both reports highlight problems with the use and understanding of Section 5(2) of the Mental Health Act 1983 as a holding power. The earlier report focuses on incomplete paperwork and lack of awareness, while the later report points out the absence of a Responsible Clinician and mental‑health liaison during the 72‑hour hold.
NHS England · National body
Delayed discharge of out-of-area patientEarlier report
“This is the second inquest I have heard where the delayed discharge/repatriation of an Out-of-Area patient from an independent provider's hospital has been a contributory factor in that patient's death.”
The response stated
“All Integrated Care Boards (ICBs) were asked to work towards eliminating the practice in NHS England's 2023/24 Priorities and Operational Planning Guidance.”
Stated timescale: 2023/24
Raised again
9 months later
“delayed transfer of an out-of-area patient from an independent provider's hospital has been a contributory factor in that patient's death”
Same coroner as the earlier report.
Both reports identify delayed discharge/repatriation of an out‑of‑area patient from an independent provider’s hospital as a contributing factor in a death. They cite underfunding of local mental health beds and over‑reliance on independent providers.
Earlier report
“The Serious Incident Investigation failed to identify the errors in the care provided to Miss [name redacted] making the use of the process somewhat otiose in this case.”
The response stated
“We will capture the learning from this inquest and other SI reports produced by the Trust and will share this learning across the Trust through our learning forums and Quality Improvement Collaboratives.”
Raised again
10 months later
“The Serious Incident Investigation into Mr [name redacted] death did uncover and accepted some failings in relation to the care provided to Mr [name redacted].”
Same coroner as the earlier report.
Both reports highlight inadequacies in the Trust's Serious Incident Investigation and Reporting processes. They differ in the specific cases examined (Miss [name redacted] vs Mr [name redacted]) and the particular aspects of the process criticised.
Department of Health and Social Care · National body
Insufficient inpatient bed capacity leading to delayed discharges and patient harmEarlier report
“The prolonged wait Mr [name redacted] had was a result of lack of bed capacity.”
The response stated
“Adoption of a single GM Discharge to Assess Referral Form - Triage of discharge to assess referrals within 30mins - Adherence to the guidance for COVID 19 testing for discharge and PPE requirements - The supply of 2 weeks medication supplies at the point of discharge from an acute hospital - Operation of a next day follow up process following discharge (localities to determine how this is delivered)”
Stated timescale: late April (formally approved)
Raised again
3 years 11 months later
“bed capacity remains an ongoing problem and has not been resolved.”
Both reports identify insufficient bed capacity as a safety issue leading to prolonged waits and risk of harm. The earlier report focuses on general emergency department bed shortages due to delayed discharges, while the later report highlights ongoing mental health bed shortages in London.
Department of Health and Social Care · National body
Insufficient inpatient bed capacity leading to delayed discharges and patient harmEarlier report
“Despite recognising Mr [name redacted] needed to be admitted to a psychiatric hospital in June 2023 but there was no bed capacity, BSMHFT' RCA report identified no remedial action.”
The response stated
“The Trust initiated a 12- month project with Grant Thornton Consultancy to address local bed shortages and reduce reliance on out-of-area hospital beds”
Stated timescale: 12-month project
Raised again
7 months later
“The Matron in Acute and Urgent Care confirmed bed capacity remains an ongoing problem and has not been resolved.”
Both reports highlight an unresolved shortage of psychiatric/mental health bed capacity leading to delayed admissions and increased risk. They differ in geographic focus (Birmingham/Solihull vs. London) and the specific witnesses cited.
Earlier report
“on 2 occasions (03/12/21 and 07/12/21) there was a failure to treat Mr [name redacted] as a missing person when he was reported as missing.”
The response stated
“WMP is currently setting up a working group with key partner agencies, including mental health agencies and professionals, to discuss and design a joint missing person protocol”
Raised again
1 year 5 months later
“I am not reassured BSMHFT staff are handing attending police officers 'appendix C - risk rating' as required by their missing person policy.”
Both reports highlight shortcomings in West Midlands Police's handling of missing‑person cases, specifically around risk assessment and information sharing.
Cwm Taf Morgannwg University Health Board · NHS body
Delayed escalation and inadequate fluid monitoringEarlier report
“(4) The failure at triage to escalate this referral to seeing a doctor within 10 mins of admission.”
The response stated
“Further training of Triage nursing staff and doctors of the sepsis 6 bundle and =e} Score (NEWS) documentation, escalation and the implementation of the Sepsis 6 bundle.”
Stated timescale: ongoing (held on hold due to COVID-19)
Raised again
4 years 3 months later
“The Health Board accepted that significant learning was required by staff regarding timeliness of escalation and maintenance of fluid balance charts”
Both reports highlight delays in recognizing patient deterioration and escalating care promptly. The earlier report focuses on triage escalation within 10 minutes, while the later report stresses timeliness of escalation and fluid balance monitoring on surgical wards.
Earlier report
“Despite a number of measures being undertaken by the North West Ambulance Service, the delay in paramedics attending Category 2 calls has not been resolved to within target ranges because there are residual staff and emergency vehicle shortages.”
The response stated
“The North West Ambulance Service (NWAS) lead commissioners, representatives from the local health system and NHS England have developed a 6-point winter improvement plan concentrating on key actions to assist in improving performance levels for 999 and Urgent and Emergency Care.”
Raised again
2 years 1 month later
“Despite a number of measures being undertaken by the North West Ambulance Service, the delay in paramedics attending Category 2 calls has not been resolved to within target ranges. This is because resources available in the North West Ambulance Service cannot be fully utilised as a result of the delays in ambulances clearing Accident and Emergency departments.”
Same coroner as the earlier report.
Both reports identify that delays in paramedics attending Category 2 calls persist because ambulance resources cannot be fully used due to hold-ups in clearing Accident and Emergency departments.
Earlier report
“In the event, the vehicle did not arrive for 2 hours 8 minutes.”
The response stated
“NWAS is currently exploring better ways to minimise lengthy waits during high demand periods and has also secured funding for 400 additional frontline staff and 60 new vehicles which | hope will assist in alleviating some of these pressures.”
Raised again
7 years 11 months later
“due to significant demand the wait time for an ambulance in category 3 was in excess of 4 hours rather than the target 1 hour.”
Both reports highlight excessively long ambulance response times caused by high demand and resource constraints. The earlier case involved a 2‑hour‑8‑minute delay for a Green 2 call; the later case notes category 3 waits exceeding 4 hours against a 1‑hour target.