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
Department of Health and Social Care · National body
Lack of psychological therapy for emotional unstable personality disorderEarlier report
“There were periods when he was under the care of the community mental health team but at this time he remained on a long waiting list for psychological services.”
The response stated
“From September 2019, subject to recruitment, we anticipate to be in a position whereby every individual Home Treatment Team has a 0.5WTE Clinical Psychologist within their team”
Stated timescale: September 2019
Raised again
3 years later
“The Court heard that patients continue to experience lengthy waits if referred for psychological therapies, both locally and nationally. In the Tameside area, the current average wait was thought to be around one year from referral.”
Both reports highlight that patients face significant delays in accessing psychological therapy services. The earlier case describes long waiting lists preventing treatment, while the later case notes ongoing lengthy waits for psychological therapies.
Cumbria County Council · Local authority
Inadequate warning signage at junctionEarlier report
“(1) The current warning signage on approach to the junction from a north westerly direction is inadequate.”
The response stated
“The scheme to introduce the high friction surfacing, improved road marking and signage is currently out to consultation with the police, the Parish Council and the local County Councillor and subject to agreement, the measures will be introduced as soon as practicable.”
Stated timescale: as soon as practicable
Raised again
4 years 5 months later
“2) The lack of appropriately positioned signage, warning approaching drivers of the possibility of vehicles crossing the carriageway from the café.”
Both reports highlight insufficient warning signage to alert drivers of hazards at a junction. The earlier report cites inadequate signage from a north‑westerly approach, while the later report notes missing signage warning of vehicles crossing from a café.
Universities and Colleges Admissions Service · Other
Mental health disclosure not distinguished from disability in UCAS applicationEarlier report
“The application invites them to disclose any history they have of mental health problems, upon being accepted on a course of study this information is provided to the admitting university.”
The response stated
“We have been reviewing the questions we currently ask applicants on the UCAS application, and considering how we can improve the flow of information between the student and the course provider.”
Stated timescale: new year
Raised again
2 years 3 months later
“The option for applicants to disclose a mental health illness should be considered separate to them confirming whether they have any 'disability' or 'special needs'”
Both reports address the design of UCAS application questions regarding mental health disclosure. They note that current wording may deter students from revealing mental health conditions.
Association of Ambulance Chief Executives · Ambulance service
Inadequate training for police and ambulance crew on acute behavioural distressEarlier report
“Acute Behavioural Disturbance (ABD) is a term used to describe the presentation of a spectrum of behaviours, signs and symptoms which create an immediate risk to life, especially at the severe end of the spectrum”
The response stated
“providing additional Continuous Professional Development training around Acute Behavioural Disturbance”
Raised again
2 years 3 months later
“Acute Behavioural Disturbance (ABD) is an umbrella term to describe a presentation which usually includes abnormal physiology and/or behaviour. ABD is not a diagnosis or a recognised syndrome, but rather a term used to describe a combination of signs and symptoms of aggression and agitation with physiological abnormalities”
Both reports concern Acute Behavioural Disturbance (ABD) as a set of behavioural and physiological signs indicating imminent risk of death requiring urgent management.
Earlier report
“Foreign National Prisoners liable for deportation who are not in an Immigration Detention Centre currently have no access to a duty lawyer scheme”
The response stated
“the MoJ Estates Directorate Technical Standards team has agreed to carry out a review of balcony design.”
Stated timescale: autumn
Raised again
3 years 1 month later
“There was a paucity of available information and the letters sent out by the Home Office were written in legal English with no offer of translation”
Both reports highlight insufficient legal information or support for foreign national prisoners facing deportation while detained. The earlier report notes the absence of a duty lawyer scheme, while the later report points out that provided communications are in complex legal English without translation or plain‑English assistance.
Earlier report
“Evidence from a wide range of clinicians who had engaged with [the deceased] in 2012 echoed the evidence of clinicians attending the four inquests of the women referred to above.”
The response stated
“NHSEI issued national guidance in August 2019 which sets out a clear expectation that CED services develop integrated pathways with primary care and where responsibility for medical monitoring sits. The guidance outlines that”
Stated timescale: August 2019
Raised again
9 months later
“Of those, only one had knowledge of MARSIPAN and his understanding of MARSIPAN was extremely limited.”
Both reports highlight inadequate training of doctors and other medical professionals regarding eating disorders, particularly concerning the MARSIPAN guidance.
Ministry of Defence · National body
Outdated care plan and risk assessmentEarlier report
“Care plan had not been updated since October 2019 and his risk assessment remained the same even when the scores changed and there was evidence of escalating risk behaviour.”
The response stated
“We recognise the importance of face to face appointments for urgent clinical assessments, particularly with respect to mental health matters. Throughout the COVID-19 pandemic in-person consultations have been offered to patients who are assessed as being at high risk. However, the pandemic has meant that in- person attendance is not always possible, or indeed preferred, by some individuals. In making available remote video consultation during the pandemic, the MOD prioritised mental health”
Stated timescale: April 2021
Raised again
1 year 1 month later
“There is no single composite risk assessment and care plan for service users that draws tooether all the relevant information for 2 a service user and identifies the plan in place (care plan and risk management plan) at any given time”
Both reports highlight deficiencies in updating and integrating risk assessments and care plans for military personnel with mental health needs.
Kernow Clinical Commissioning Group · Commissioner
Premature discharge from community mental health servicesEarlier report
“The discharge from CMHT on failing to attend two appointments.”
The response stated
“To review the approach taken in cases of non-attendance at mental health appointments, and whether attempts to contact service users should be undertaken or alternatively to involve the police if there are concerns for the individuals welfare..”
Stated timescale: December 2018
Raised again
3 years 5 months later
“clients referred to the Trust were too easily discharged”
Both reports concern premature discharge of patients from community mental health services, particularly those with dual diagnosis. They highlight gaps in follow‑up and coordination leading to inadequate ongoing care.
Earlier report
“| am concerned about the lack of appropriate clinical supervision and guidance for junior medical staff. Two junior doctors were asked to attend the ward and made no appropriate clinical records of the reason for their attendance, reviewing the records, seeing the patient and explaining any clinical decision to prescribe medication.”
The response stated
“A revised governance process has been developed within the Citywide Commissioning, Quality and Safeguarding Team and the Trust now attends an established Citywide Patient Safety Committee. This committee meets monthly and is responsible for the review and monitoring of serious incidents requiring investigation reported by the Trust as well as any other patient safety related issues including those highlighted at inquest via Prevention of Future Death Reports.”
Raised again
7 years 10 months later
“The inquest heard that due to the time of her arrival in the Emergency Department on 11th December 2020 consultants were not on site. The most senior doctors available were middle grade and the number available at that time of night was significantly reduced.”
Both reports highlight inadequate supervision and support of junior medical staff as a safety concern. The earlier report focuses on missing clinical supervision and record‑keeping, while the later report stresses staffing shortages that hinder supervision, especially at night.
NHS England · National body
Manipulable medication suitability questionnaireEarlier report
“Permitting the patient to”
The response stated
“We have responsibility for ensuring that GPs work within the terms of their contract and pharmacies adhere to their Terms of Service which are outlined in the NHS (Pharmaceutical and Local Pharmaceutical Services) Regulations 2013). The Board can take action such as issuing breach notices and requiring action or withholding payments in certain circumstances.”
Raised again
3 years 2 months later
“There was a very limited questionnaire about the history of the person requesting the drugs.”
Both reports highlight that the questionnaire used to assess suitability for medication can be easily manipulated or lacks sufficient verification, opening the system to abuse.
NHS England · National body
Uncontrolled prescribing of contraindicated drugsEarlier report
“There is evidently no central database of all prescription errors so there can be no central monitoring of such errors and no means of determining trends or particular repeat errors.”
The response stated
“The medicines regulator, the MHRA, has been working with NHS England to develop draft Patient Safety Alerts and guidance to increase adverse incident reporting via the National Reporting and Learning System (NRLS), which is a central database of patient safety incident reports. We continue to work with the MHRA and NHS England to ensuring that pharmacists and pharmacy technicians use the NRLS.”
Raised again
7 years 9 months later
“There is no central tracking system or central database to record what each person has been prescribed and dispensed and by whom.”
Both reports highlight the absence of a central database/system to monitor prescription errors and track prescriptions across providers.
Association of Ambulance Chief Executives · Ambulance service
Inadequate training for police and ambulance crew on acute behavioural distressEarlier report
“lack of understanding of how to treat someone with an acute behavioural disturbance”
The response stated
“We have made a recommendation to the National Education Network for Ambulance Services leads (NENAS) that each trust considers including, if not completed already, the education of front line staff and control room staff in acute behavioural disturbance to raise awareness of the condition and how it can present in a patient.”
Stated timescale: November 2015
Raised again
6 years 7 months later
“insufficient or inadequate instruction of both police and ambulance crew about the critical issues of recognising and responding to a medical emergency and the effects of restraint including positional asphyxia.”
Both reports address gaps in training regarding recognition and response to behavioral/medical emergencies during restraint.