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
“I heard evidence that NWAS failed to meet target times which are nationally set by the Department of Health and that although NWAS was given more financial resources”
The response stated
“I am advised that work is underway to increase the training of the Fire Service to Extended Community First Responder levels.”
Raised again
4 years 10 months later
“target response times are still routinely not being met nationally.”
Both reports highlight that national ambulance response time targets are not being met. They refer to the same systemic issue of delayed responses despite previous interventions.
Earlier report
“The target time for the arrival of the ambulance was 8 minutes, this was breached. The ambulance did not arrive for 15 minutes.”
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
7 years 1 month later
“target response times are still routinely not being met nationally. By way of illustration, the court heard evidence that on 21st June 2021, the Trust's average response”
Both reports highlight that ambulance services are failing to meet required response times. The earlier report details a specific breach of an 8‑minute target, while the later report notes ongoing national failures to meet category 2 response targets.
NHS England · National body
Missing mental health assessment in police custodyEarlier report
“FOR SEPT:- The admitted lacuna in the SEPT admissions protocol governing the transfer of mentally disordered people from police custody.”
The response stated
“The following information describes the commissioning arrangements for healthcare for someone being held in police custody.”
Raised again
5 years 4 months later
“The L&D police custody suite model has not commissioned psychiatrists.”
Both reports highlight a gap in mental‑health provision for individuals detained in police custody, specifically the absence of psychiatrists or proper transfer protocols.
Surrey and Borders Partnership NHS Foundation Trust · NHS body
Delayed reporting of missing detained patientEarlier report
“- Training procedures in respect of the police and hospital staff on Elgar Ward in the case of reports of missing persons and lack of understanding of areas of responsibility and appropriate actions.”
The response stated
“We have further emphasised the importance of the Missing Persons (MISPER) process to all our staff on these units, including making this a part of our improvement work in the reduction of the numbers of people who may be Absence Without Leave (AWOL). A member of the Clinical Assurance team is specifically assigned to wards with the view to ensure compliance with the MISPER agreement is tested.”
Stated timescale: end of February 2015
Raised again
7 years 7 months later
“The court heard evidence from some members of staff who gave evidence that they were not aware of a particular timeframe for instigating the missing persons protocol in relation to informal patients, and as such I consider there is a risk of future delays in reporting informal patients as missing persons to police, which presents a risk of future deaths.”
Both reports highlight failures in timely activation of missing‑person protocols due to insufficient staff training/awareness.
Surrey and Borders Partnership NHS Foundation Trust · NHS body
Delayed reporting of missing detained patientEarlier report
“The timeframe for reporting informal patients to the police as missing persons if they fail to return at the agreed time.”
The response stated
“This issue is going to be covered in the new policy regarding leave for informal patients, as outlined above. We are also going to update our Section 17 Leave policy (for detained patients) and our Absent Without Leave policy with the same guidance.”
Raised again
1 year 6 months later
“staff were aware that he had not returned from 18:45 onwards. The court found that thereafter there was a delay of approximately two hours in instituting the missing persons protocol”
Same coroner as the earlier report.
Both reports highlight a lack of clear timing for initiating missing‑person procedures when patients do not return as expected. The earlier report focuses on absent written policy/timeframe for detained patients, while the later report points to staff unawareness of the immediate reporting requirement for informal patients.
Earlier report
“During periods of heavy rainfall surface water from the adjoining road known as Coliza Hill is likely to converge with surface water on the A390 in the vicinity of where [the deceased] initially lost control of his car”
The response stated
“Signs will shortly be erected on both approaches warning of the possibility of surface water on the road ahead. This is an interim measure pending more substantial improvement.”
Stated timescale: shortly
Raised again
1 year later
“During periods of heavy rainfall surface water from the adjoining road known as Coliza Hill is likely to converge with surface water on the A390 in the vicinity of where [the deceased] initially lost control of his car”
Same coroner as the earlier report.
Both reports describe the same hazard: surface water from Coliza Hill converging with water on the A390 during heavy rain, creating aquaplaning risk.
London Ambulance Service NHS Trust · Ambulance service
Delayed symptom recognition leading to missed emergency responseEarlier report
“The LAS failed to make a relevant and proper note of the symptoms of the deceased when these were phoned through to the LAS.and as a result the clinicians at LAS made an incorrect priority decision”
The response stated
“The LAS failed to make a relevant and proper note of the symptoms of the deceased when these were phoned through to the LAS and as a result the clinicians at LAS made an incorrect priority decision which caused significant delay in a timely attendance being made on the deceased.”
Raised again
3 years 10 months later
“It was apparent that the ambulance crew were not aware that the combination of seizures and cocaine represented a medical emergency”
Both reports highlight failures in recognizing critical symptoms during ambulance calls, leading to inappropriate prioritisation and delayed emergency response.
Earlier report
“when a hard shoulder is used as a running lane. Whilst any vehicle may break down on any road, in relation to motorways:”
The response stated
“assist. We will be repeating our information campaigns on using motorways in four waves between early 2020 and March 2021. These will be focused on 'what to do in a breakdown', Red X, keeping left and variable speed limits.”
Stated timescale: early 2020 to March 2021
Raised again
2 years 4 months later
“(1) On the date of the death the particular section of the M4 motorway was not completed as a smart motorway, but was substantially in course of conversion such that to all intents and purposes it had the intended characteristics of a smart motorway”
Both reports highlight the danger posed when motorists cannot reach a safe refuge because the hard shoulder is absent or being used as a running lane. They share the concern that a stationary vehicle in a live lane creates a high‑risk situation for following traffic.
Earlier report
“- The obvious and foreseeable risk posed by the absence of a hard shoulder on smart motorways;”
The response stated
“Highways England will publish this report shortly”
Stated timescale: shortly
Raised again
1 year 2 months later
“the policy of mixing smart motorways with traditional hard shoulder motorways created a latent risk that road users will become accustomed to treating the left or inner lane of motorways as a live running lane”
Both reports highlight dangers arising from the lack or ineffective use of a hard shoulder on motorways. They differ in focus: the earlier cites the absence of a hard shoulder on smart motorways, while the later warns that mixing smart and traditional designs leads drivers to misuse lanes.
Surrey and Borders Partnership NHS Foundation Trust · NHS body
Delayed reporting of missing detained patientEarlier report
“- The timeframe for reporting informal patients to the police as missing persons if they fail to return at the agreed time.”
The response stated
“This issue is going to be covered in the new policy regarding leave for informal patients, as outlined above. We are also going to update our Section 17 Leave policy (for detained patients) and our Absent Without Leave policy with the same guidance.”
Raised again
1 year 3 months later
“There was no missing person plan in place with timeframe and steps of escalation for [the deceased]'s leave.”
Both reports highlight the absence of a clear timeframe and procedure for reporting patients who go missing during leave.
Earlier report
“Ms [name redacted] was prescribed methadone in hospital and died of a methadone overdose, but her drug chart was not available at inquest and appears to have been lost.”
The response stated
“The Trust is moving in 2019-20 to electronic prescribing. This will eliminate the need for paper based drug charts, and the attendant risk of them being mislaid or lost.”
Stated timescale: 2019-20
Raised again
3 years 3 months later
“Despite awareness of the previous overdoses on the ward, there was no itemised property list, including a list of medications.”
Both reports highlight failures in documenting patients' medication information, which can lead to unsafe prescribing and overdose risks. The earlier case concerned a lost paper drug chart; the later case notes the absence of an itemised property list of medications.
Earlier report
“A target waiting list of 18 weeks is far too long but | was told that this was a funding issue.”
The response stated
“The reviewing team are using this information alongside an exploration of alternative models of care to develop a new model of psychological therapy for people with complex mental health needs in Tameside and Glossop. This review will conclude by the 31 of July 2019.”
Stated timescale: 31 July 2019
Raised again
3 years later
“The inquest heard evidence that the backlogs for therapy were such that the waiting list at the time she was assessed as being appropriate for step 4 therapy had a two year wait time.”
Both reports highlight excessively long waiting times for mental health therapy as a safety concern. The earlier report cites an 18‑week target due to funding, while the later report describes waits of 2‑3 years caused by therapist shortages.