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 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 which led to a delay in formulating a treatment plan in tertiary services;”
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
8 months later
“The evidence before the inquest was that there were multiple specialisms across multiple GM Trusts with different IT systems involved in Mr [name redacted] care. As a consequence communication was poor with a limited understanding of his overall condition and fragmented input.”
Same coroner as the earlier report.
Both reports highlight problems with delayed or ineffective referrals due to fragmented systems and poor communication across trusts.
Earlier report
“long delays in ambulance response to Category 2 calls create a risk that other deaths will occur in the future”
The response stated
“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 to 30 minutes on average this year”
Stated timescale: 2023/24
Raised again
10 months 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”
Both reports highlight that delays in responding to Category 2 ambulance calls remain unresolved and pose a risk of future deaths. The earlier report cites persistent ineffectiveness of actions, while the later points to ongoing staff and vehicle shortages.
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
1 year 11 months 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 because there are residual staff and emergency vehicle shortages.”
Same coroner as the earlier report.
Both reports identify that delays in paramedics attending Category 2 calls persist despite measures, due to residual staff and emergency vehicle shortages. They also note that ambulance resource use is limited by A&E department pressures across the NHS.
Department of Health and Social Care · National body
Insufficient inpatient bed capacity leading to delayed discharges and patient harmEarlier report
“The inquest heard that [the deceased] was kept in an acute hospital setting at Salford Royal Hospital awaiting a mental health bed due to a shortage of mental”
The response stated
“the Department is investing £150 million for significant improvements in the mental health estate over the course of the Spending Review (2021). This will be used to support our NHS Long Term Plan ambitions regarding system capacity and pressure reduction. It will cover a range of schemes, including non-medical alternatives to admission, step-down community beds and supported living services.”
Stated timescale: 2021
Raised again
1 year 10 months later
“Had an informal Mental Health bed been available on the 6th June 2023, and [the deceased] had been admitted as both she and her psychiatrist had wished, her death would not have occurred.”
Both reports highlight insufficient mental health inpatient bed capacity leading to delayed or adverse outcomes for patients needing care. They differ in the specific context: one concerns a general bed shortage causing a patient to remain in an acute hospital, while the other focuses on the lack of an informal mental health bed preventing timely admission.
Department of Health and Social Care · National body
Insufficient inpatient bed capacity leading to delayed discharges and patient harmEarlier report
“The deceased was under the care of the Avon and Wiltshire Mental Health Partnership. The day before his death the deceased made it clear he wished to be admitted to hospital for his own safety.”
The response stated
“The Trust Board closely monitors bed pressures and out of area placements and is continually working with its Commissioners and NHS England to manage the situation optimally.”
Raised again
8 years 11 months later
“Had an informal Mental Health bed been available on the 6th June 2023, and [the deceased] had been admitted as both she and her psychiatrist had wished, her death would not have occurred.”
Both reports highlight a shortage of mental health beds that prevents patients who wish to be admitted from receiving inpatient care.
Nottinghamshire Healthcare NHS Foundation Trust · NHS body
Limited family involvement in care planning and risk assessmentEarlier report
“There was extremely limited family and carer involvement in [the deceased]'s care, with no involvement in the care plan, nor involvement in ward rounds on ward B2 now Beech ward”
The response stated
“The Triangle of care process has also been strengthened as part of our ongoing quality improvement plans. Our Quality Standards Team also undertake reviews of Care Plans and look for clear evidence that these plans are produced with the patient, family and carers.”
Raised again
6 months later
“Family are not routinely or regularly involved in a patients risk assessment, care plan and safety planning.”
Same coroner as the earlier report.
Both reports highlight the lack of routine family and carer participation in patients' risk assessments, care planning and safety processes.
Network Rail · National body
Public access to live rail at platform endEarlier report
“Recommendations in The BTP Post Fatality Report to create a safer environment at the bridge and restrict public access to the railway had not been effected by the time of the inquest.”
The response stated
“We are in the process of installing acoustic fencing on both sides of the track at a height of 3m. This will also have anti-climb wire extensions fitted as an additional deterrent at certain sections.”
Raised again
8 years later
“I was provided with evidence that there have been three (non-fatal) incidents in the vicinity of the Hackney Central/Dalston Kingsland areas of the rail network in the 12 months prior to this incident on 23 September 2023”
Both reports highlight that members of the public can gain access to the railway tracks in the area. The earlier report notes unimplemented recommendations to restrict access, while the later report points to existing physical mitigations that proved ineffective.
Network Rail · National body
Public access to live rail at platform endEarlier report
“I am concerned that the railway track is easily accessible to members of the public from this bridge.”
The response stated
“Network Rail is planning to apply mitigation measures (wire mesh panels with base plated fence posts fixed to the top of the parapet walls) to the parapet walls to further deter access to the track below. An order has now been placed with Network Rail's framework contractors in respect of these works, with an anticipated completion date of the end of September 2018.”
Stated timescale: end of September 2018
Raised again
5 years 8 months later
“The concern here is that there is evidence to suggest that access to the railway tracks by members of the public may be a frequent issue in this vicinity.”
Both reports highlight that members of the public can readily access the railway tracks from a bridge or wall structure. The later report notes similar accessibility issues despite existing mitigation measures.
Kent and Medway NHS and Social Care Partnership Trust · NHS body
Carers not advised of suicide risk behavioursEarlier report
“Carers were not advised about any behaviours that might indicate an increased risk”
The response stated
“The Trust has re-launched its carers protocol in February 2016 across the service which includes an outline of possible "red flags", and what behaviours carers may look out for”
Stated timescale: February 2016
Raised again
8 years 1 month later
“was not aware of any issues in relation to mental health, the fact of the deprivation of liberty order, or that [the deceased] was a risk of deliberate self harm”
Same coroner as the earlier report.
Both reports highlight that carers were not given essential information about risks of self‑harm or suicide that would enable them to recognise warning signs.
Earlier report
“The delay in an ambulance being despatched to the home address of the deceased who was clearly experiencing seizures/fits.”
The response stated
“We recognise lengthy handover delays are clearly unacceptable as they can impact not only on the ambulance service's ability to respond to subsequent calls in the community, but also on patient's experience. Handover delays are often symptomatic of pressures elsewhere within the unscheduled care system and should not be viewed in isolation which is why work is being undertaken nationally and locally to support improvements across the patient pathway through reducing inappropriate admissions to hospital”
Raised again
7 years later
“Despite having their full complement of ambulance resources staffed and on shift many of them were held up by delays in handover at hospitals;”
Both reports identify hospital handover delays as the cause of ambulance resource unavailability. They describe the same failure point affecting timely ambulance response.
Earlier report
“As against an internal Welsh Ambulances Services Trust response target time for an Amber 2 call of 20 minutes, an ambulance did not arrive at the scene for nearly 2 hours and 40 minutes.”
The response stated
“Please find attached a copy of the Action Plan that the Welsh Ambulance Services NHS Trust has developed as a result of this Regulation 28.”
Stated timescale: 9 June 2016
Raised again
7 years 10 months later
“Welsh Ambulance Service Trust were unable to allocate an available ambulance resource in an Amber 1 category call until over 6 hours from the time of the 999 call;”
Both reports highlight prolonged delays in ambulance response due to insufficient resource availability and system pressures.
His Majesty's Prison and Probation Service · National body
Lack of basic first aid training and CPR among prison officersEarlier report
“One frontline prison staff member gave evidence that he had not received training in 16 years of working for HMPS and felt he needed refresher training.”
The response stated
“The Governors of each prison are required to ensure that there are sufficient numbers of staff trained in first aid on duty, and at HMP Lewes at least two trained nurses and one trained member of prison staff are available at all times. Two on-site first aid trainers will be delivering first aid training to staff as part of the prison's monthly training provision, and a one-day refresher course will be introduced to ensure that training levels are maintained. Custodial Managers (the most senior”
Raised again
4 years 8 months later
“It is not mandatory for prison officers to have basic first aid training (which includes the provision of CPR) which is in-date.”
Both reports highlight that prison staff do not reliably maintain up‑to‑date first aid training, leaving gaps in emergency response capability.