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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Earlier report
“Leave was considered first on 1.11.2013 when Mrs. [name redacted] was on 15 minute observations.”
The response stated
“We have since reinforced with staff that should these quite extraordinary circumstances arise again then a retrospective note must be completed.”
Raised again
12 years 2 months later
“staff are unaware of leave conditions and this is not being properly monitored.”
Both reports highlight failures in the leave process where staff do not follow or are unaware of required checks and documentation.
Earlier report
“when the Emergency Department of the Royal Sussex County Hospital, Brighton reached capacity patients would be moved to and treated in the corridor as there was no clinical area available to do so”
The response stated
“NHS England is working through the operating model so that NHS England's Regions can support providers to eliminate crowding in Emergency Departments in the longer term.”
Raised again
1 year 7 months later
“there were around 20 patients in the corridor as the Department had reached capacity and there was no clinical area available to do so”
Same coroner as the earlier report.
Both reports describe patients being treated in the Emergency Department corridor because the department has reached capacity and lacks a designated clinical area.
Earlier report
“when the Emergency Department of the Royal Sussex County Hospital, Brighton reached capacity patients would be moved to and treated in the corridor as there was no clinical area available to do so.”
The response stated
“In June 2025, NHS England published the Urgent and Emergency Care (UEC) Plan for 2025/26, which included an ambition to 'improve flow through hospitals with a particular focus on patients waiting over 12 hours and making progress on eliminating corridor care'.”
Stated timescale: 2025/26
Raised again
10 months later
“there were around 20 patients in the corridor as the Department had reached capacity and there was no clinical area available to do so.”
Same coroner as the earlier report.
Both reports describe patients being treated in emergency department corridors due to lack of clinical space when the department reaches capacity.
His Majesty's Prison and Probation Service · National body
Lack of basic first aid training and CPR among prison officersEarlier report
“There is no mandatory first aid training for existing (as opposed to new) prison officers.”
The response stated
“Following the inquest I have reflected and reviewed healthcare processes and there have been discussions within the healthcare team. Going forward we will ensure that the Local Operating Procedures (LOPs) are embedded, with senior management undertaking audits, to ensure that where any relevant risks and triggers are identified, we will share information with the prison in the following ways:- - Update on C nomis - entry to be made by allocated healthcare staff - Update the ACCT document and”
Raised again
8 years 5 months later
“After prison officers and prison staff carry out their induction training which covers basic first aid training including the delivery of cardio pulmonary resuscitation (CPR), there is no further mandatory refresher training on first aid or CPR.”
Both reports highlight a gap in ongoing first aid/CPR training for prison staff, leaving them unprepared for medical emergencies. The earlier report notes no mandatory training for existing officers, while the later report notes no refresher training after initial induction.
His Majesty's Prison and Probation Service · National body
Lack of basic first aid training and CPR among prison officersEarlier report
“It is not mandatory for prison officers to have basic first aid training (which includes the provision of CPR) which is in-date. Once a prison officer's three-year period has expired, whilst they may be reminded by the prison establishment that their certification is no longer live, it is not mandatory for them to renew this.”
The response stated
“Following evidence heard at the inquest, you have raised some concerns regarding the first aid training for staff, particularly in relation to the use of CPR. Thank you for bringing your concern to my attention. As you are aware, the HMPPS First Aid Policy Framework was re-issued nationally in August 2023. The revised policy highlights the training requirements for Emergency First Aid and First Aid in prisons, including the importance of Governors ensuring that there is an appropriate number of”
Stated timescale: August 2023
Raised again
2 years 3 months later
“After prison officers and prison staff carry out their induction training which covers basic first aid training including the delivery of cardio pulmonary resuscitation (CPR), there is no further mandatory refresher training on first aid or CPR.”
Both reports highlight that prison staff are not required to undertake ongoing or refresher first aid/CPR training after initial certification. They describe the same gap in mandatory training leading to potentially outdated life‑saving skills.
His Majesty's Prison and Probation Service · National body
Lack of basic first aid training and CPR among prison officersEarlier report
“Evidence was heard that the majority of those prison officers who had commenced in their roles prior to 2018 had no first aid/basic life-saving skills and no ability/training in undertaking cardiopulmonary resuscitation ('CPR').”
The response stated
“attention. The HMPPS First Aid Policy Framework was re-issued nationally in August 2023. The revised policy highlights the training requirements for Emergency First Aid and First Aid in prisons, including the importance of Governors ensuring that there is an appropriate number of trained staff on duty at all times. To achieve this, a detailed local first aid risk assessment must be produced to determine the number of First Aiders at Work (FAW) and Emergency First Aiders at work (EFAW) required at an”
Stated timescale: August 2023
Raised again
1 year 7 months later
“After prison officers and prison staff carry out their induction training which covers basic first aid training including the delivery of cardio pulmonary resuscitation (CPR), there is no further mandatory refresher training on first aid or CPR.”
Both reports highlight the absence of ongoing or refresher first aid and CPR training for prison officers after initial instruction. They differ in the timing and scope of the training gap described.
Metropolitan Police Service · Police
Inconsistent mental health emergency protocols across police forcesEarlier report
“I heard that the MPS has already created a similar model under the resource and demand team. The protocol is called Affinity.”
The response stated
“Response The MPS currently has the Affinity Protocol in place and has done since September 2021.This is a collaborative partnership between local policing, NHS Trusts and mental health service providers, the aim of which is to achieve mutual understanding of each partner's responsibilities in respect of those patients detained under the Mental Health Act and who may abscond.”
Stated timescale: September 2021
Raised again
2 years 11 months later
“An overly rigid approach to the Right Care Right Person policy and affinity protocol resulted in a delayed deployment.”
Both reports highlight problems with the Metropolitan Police Service's implementation of the Right Care Right Person/Affinity protocol concerning mental health responses. The earlier report notes a lack of guidance for staff assisting escorts, while the later report describes an overly rigid application that removes discretion and delays deployment.
College of Policing · National body
Overly rigid right care right person policy leading to deployment delaysEarlier report
“some parts of these policies remain ambiguous or confusing. For example, in the Call Handling, Grading and Deployment Policy, there is no specific paragraph that explains that the Force Incident Manager should be notified of a high risk missing person”
The response stated
“The College very much recognise the issues you raise in relation to the lack of effective and consistent communication between services for people with neurological conditions and mental illness.”
Raised again
3 years 10 months later
“An overly rigid approach to the Right Care Right Person policy and affinity protocol resulted in a delayed deployment. Even where call handlers have real concerns that someone not returning to a mental health unit is a high risk missing person, the outcome of the toolkit not to deploy is the same if the individual's address has not been visited, even when told that they would not go there.”
Both reports highlight problems with the application of the Right Care Right Person/affinity protocol leading to delays in deploying help for high‑risk missing persons.
College of Policing · National body
Overly rigid right care right person policy leading to deployment delaysEarlier report
“The emergency response had come about because of a new 'Right Care, Right Person' policy applied by emergency services that, in fact, delivered as a first responder, the wrong person delivering the wrong care to the deceased's residence.”
The response stated
“The College is reviewing the RCRP toolkit to ensure it provides clearer guidance on the assessment of risk in control rooms, including how to handle ambiguous or borderline cases where the threshold for police attendance may not be immediately clear.”
Raised again
10 months later
“An overly rigid approach to the Right Care Right Person policy and affinity protocol resulted in a delayed deployment.”
Both reports highlight problems arising from an overly rigid application of the Right Care, Right Person policy, leading to inappropriate emergency responses.
Earlier report
“Evidence was heard that the majority of those prison officers who had commenced in their roles prior to 2018 had no first aid/basic life-saving skills and no ability/training in undertaking cardiopulmonary resuscitation ('CPR').”
The response stated
“attention. The HMPPS First Aid Policy Framework was re-issued nationally in August 2023. The revised policy highlights the training requirements for Emergency First Aid and First Aid in prisons, including the importance of Governors ensuring that there is an appropriate number of trained staff on duty at all times. To achieve this, a detailed local first aid risk assessment must be produced to determine the number of First Aiders at Work (FAW) and Emergency First Aiders at work (EFAW) required at an”
Stated timescale: August 2023
Raised again
1 year 7 months later
“No ongoing training had been provided to prison officers since initial training on basic life support or first aid, meaning that officers confronted with discovery of a ligature situation were unable to provide immediate and basic life support due to a lack of confidence and unfamiliarity of what to do”
Both reports highlight that prison officers lack ongoing first aid/CPR training, impairing their ability to deliver immediate life‑saving care.
Central and North West London NHS Foundation Trust · NHS body
Inadequate ACCT documentation and communicationEarlier report
“(9) The jury also found that not all members of the ACCT Review team fully reviewed the ACCT document before making a decision.”
The response stated
“CNWL Offender Care has developed its own bespoke training for the management of harm and suicide in prison environments. This training forms part of our mandatory training list and is retaken annually by all staff. Across Offender Care, we are currently 94% compliant with this requirement.”
Raised again
8 years 9 months later
“1.ACCT documentation and operation. The evidence disclosed serious difficulty in the recording, communication, and use of ACCT documentation.”
Both reports highlight problems with how ACCT documentation is handled, specifically gaps in reviewing, recording, and communicating the information.
His Majesty's Prison and Probation Service · National body
Inadequate ACCT training leading to incomplete documentationEarlier report
“In evidence it was clear that the ACCT document was the only written document used for sharing information between the healthcare staff employed by the NHS trust and the prison security staff.”
The response stated
“The Safety Intervention Meeting (SIM) is a multi-disciplinary safety risk management meeting, chaired by the Senior Management Team (SMT), providing support and multi-disciplinary guidance to Case Coordinators and case review teams.”
Raised again
3 years later
“After the first overdose, there was a handover miscommunication as to whether the ACCT remained open or had been closed.”
Both reports highlight problems with the ACCT document as the primary means of sharing information between healthcare and prison staff, noting gaps in recording and communication.