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 calls (999) to the ambulance service were properly coded and applied by the call-taker leading to a Green 2 response. This should have led to a vehicle attending within 20 minutes. 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
“The ambulance service was called at 0245 on 21 July 2022 and the call was coded as a Category 2 at 0251 call requiring a response within 40 minutes. The ambulance finally arrived at 0731 on 21 July 2022, 4 hours and 46 minutes after the call.”
Both reports highlight that ambulance services took far longer than the target response time to reach patients. The core issue is excessive delays in ambulance arrival despite appropriate call categorisation.
Earlier report
“The evidence before the inquest was that in her case the response time on the category 2 call was 1 hour and 5 minutes - significantly outside the target time.”
The response stated
“we published our 'Delivery plan for recovering urgent and emergency care services' which aims to deliver sustained improvements in waiting times”
Stated timescale: March 2025
Raised again
10 months later
“although I did hear that it is not uncommon for around 30% of available ambulances to still be held up at hospitals in our area waiting for a handover.”
Both reports highlight ambulance response delays caused by ambulances being held up at hospitals awaiting handover or bed availability. The earlier report focuses on overall system demand and A&E congestion, while the later report emphasizes specific hospital handover delays and bed blocking.
Earlier report
“I heard evidence from the consultant psychiatrist responsible for Ms [name redacted] care at Crisis House that it is not routine for the crisis team to involve family members in the care of a patient.”
The response stated
“We have also reinforced the importance of working with families in our updated, risk assessment training which has been rolled out over the last 12 months.”
Stated timescale: last year
Raised again
7 years 3 months later
“Mr [name redacted] lived with his sister, who wanted very much to be involved with his care. However, I did not hear any evidence of engagement with her by C&I, either:”
Both reports highlight insufficient involvement of families in patients' care and communication. The earlier report focuses on not routinely inviting family to meetings and unanswered calls; the later report notes a general lack of family engagement across services.
Earlier report
“I remain very concerned about resource issues for this ambulance service. I raised similar concerns in a Prevention of Future Deaths Report”
The response stated
“The need for an urgent review of resources to reduce the risk of future deaths”
Stated timescale: 2016/17 contract
Raised again
7 years 11 months later
“There was 3 available ambulance resource within the sector at that point in time with 54 Category 2 and 43 Category 3 cases awaiting resource allocation”
Both reports highlight insufficient ambulance resources leading to delayed responses and risk to patients. The earlier report cites general resource shortages and capacity management plans, while the later report specifies that hospital handover delays caused the resource shortage.
Earlier report
“The ambulance service was called again on 7 August 2022 at 07.38 hours and the call was now coded as a Category 2 call, requiring a response within 40 minutes and with an average time of 18 minutes.”
The response stated
“we published our 'Delivery plan for recovering urgent and emergency care services' which aims to deliver sustained improvements in waiting times, including to reduce Category 2 response times (including for serious conditions such as heart attacks and strokes) to 30 minutes on average this year”
Stated timescale: this year
Raised again
7 months later
“could not resource the category 2 disposition within national target times (mean average of 18 minutes, 90th centile of 40 minutes)”
Both reports highlight that the ambulance service could not meet Category 2 response time targets because of high demand and delays at hospital handover.
Earlier report
“During the inquest evidence was given that ambulance availability is being jeopardised by crews being delayed at hospital when handing patients over to Accident and Emergency staff.”
The response stated
“We will be meeting with NEAS in September 2015 to discuss and monitor how they are managing their delivery of the service, what is their current position of staffing levels and identified vacant posts and their current recruitment position.”
Stated timescale: September 2015
Raised again
8 years 11 months later
“availability of ambulance crews is continuing to be compromised by delays at hospitals resulting in delays in response times which creates a risk to the life.”
Both reports describe ambulance crew availability being compromised by delays at hospitals during patient handover, leading to longer response times and risk to life.
Earlier report
“During the course of the evidence it became clear that the poor quality nursing notes and the lack of information of the observation chart made it difficult for the reviewing Consultants to get a clear picture of events that had been occurring.”
The response stated
“1. The Emergency Department has considered the use of scribes in the course of resuscitation within the emergency department. The Matron, has discussed this with the Care Group Educator and work has commenced on training individuals as scribes in such situations and to ensure that observations are accurately collated and recorded in the course of the”
Stated timescale: end of April
Raised again
6 years 1 month later
“There was evidence of poor record keeping on the ward. This included behaviour charts, enhanced patient supervision records and daily evaluation charts not being consistently recorded.”
Both reports highlight inadequate record‑keeping practices that hinder clinical review and patient safety. The earlier report focuses on nursing notes and observation charts in resuscitation, while the later report concerns ward‑based charts and documentation of professional input.
Norfolk and Suffolk NHS Foundation Trust · NHS body
Restricted access to treatment for borderline personality disorderEarlier report
“Under the proposed new system, in order to access the Norfolk and Suffolk Foundation Trust Borderline Personality Disorder service, those suffering from the condition would have to agree”
The response stated
“STORM training includes specific training on safety planning, and our Dialog+ care planning tool is used to collaboratively create a safety plan for every adult and working age adult under our care. Our Youth teams have formed their own safety planning documentation which is co-produced with our young service users.”
Raised again
4 years 11 months later
“The adequacy of Norfolk and Suffolk NHS Foundation Trust's (NSFT) Integrated Delivery Team (IDT) decision making concerning the discharge of a patient from mental health services in circumstances where a failed engagement has occurred.”
Both reports highlight problems with how the Integrated Delivery Team handles patient pathways and decisions affecting access to care. The earlier report focuses on a barrier created by requiring transfer agreement, while the later report concerns inadequate discharge decisions after failed engagement.
Earlier report
“(1 During the course of the inquest, evidence suggested that access to the site was gained by insecure fencing.”
The response stated
“There has been an extension to the palisade fencing to prevent access by climbing around the side of the fencing to the over bridge that carries the disused line from which [the deceased] climbed down.”
Raised again
8 years 8 months later
“Car park line side fencing being too low. The proposed mitigation was replacement of the fencing.”
Both reports highlight inadequate fencing that allowed unauthorized access to a railway site. The earlier report cites insecure fencing generally, while the later report specifies that the car‑park line‑side fencing was too low.
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 10 months later
“The ambulance finally arrived at 0542 on 4 November 2022, 1 hour and 56 minutes after the call.”
Both reports highlight unacceptably long delays in ambulance arrival after an emergency call.
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. However, this could not happen as no bed was available within the area.”
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 1 month later
“The court also heard that there is an ongoing shortage of available inpatient psychiatric beds in Surrey and that this is in the context of a national shortage of inpatient psychiatric beds.”
Both reports highlight an insufficient supply of inpatient psychiatric beds leading to risks for patients needing admission. The earlier report focuses on local bed shortages and distant out‑of‑area options in Birmingham, while the later report notes an ongoing bed shortage in Surrey within a national context.
Royal College of Psychiatrists · National body
Lack of formal liaison between NHS and private mental health providersEarlier report
“That there was no requirement for ,or system for, a lead clinician from either the private or NHS treating teams to oversee and coordinate the care provided to Mr [name redacted] by the private and NHS mental health services.”
The response stated
“The College is aware that CPA policy can be interpreted and applied differently across the country. Ideally a care co-ordinator will be able to negotiate patient discharges and their integration into the care of a new team. However, there are circumstances in which this is not straight-forward, e.g. if a section is ending or a person is being discharged from hospital.”
Stated timescale: 2nd November 2017
Raised again
6 years 9 months later
“However, there is a national lack of co-ordination of treatment and communication between NHS and private providers of mental health care with no formal or informal mechanism or processes in place to liaise with each other to ensure the best mental health care and safety of their clients.”
Both reports highlight the absence of effective coordination mechanisms between NHS and private mental health services. The earlier report focuses on missing lead clinician oversight, while the later report notes a national lack of formal or informal liaison processes.