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
Association of Ambulance Chief Executives · Ambulance service
Inadequate training for police and ambulance crew on acute behavioural distressEarlier report
“College of Policing issued a training package at the end of 2016 to all Police Forces on ABD.”
The response stated
“the College will work with police stakeholders through the NPCC First Aid Forum and the national clinical governance panel to reflect this learning outcome in Module 2, the refresher training module for front line staff. This will ensure that this training is given to all front line officers. This amendment will be made as part of the wider scheduled review of the FALP following the release of updated guidance by the UK Resuscitation Council in 2020.”
Stated timescale: 2020
Raised again
1 year 11 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 highlight gaps in training for recognizing and managing acute behavioural disturbance/medical emergencies involving restrained individuals.
Greater Manchester Mental Health NHS Foundation Trust · NHS body
Inadequate audit of observations and documentationEarlier report
“without appropriate audit and clinical/nursing leadership this may prove to be ineffective.”
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
“There was no robust audit system for checking compliance with the Trusts own policies and protocols in particular with regard to medical record keeping, risk assessments and reviews.”
Same coroner as the earlier report.
Both reports highlight a lack of effective audit or oversight to ensure that existing policies are followed in practice. The earlier report stresses the need for audit to make handover procedures work, while the later report notes absent audit for compliance with record‑keeping and risk‑assessment protocols.
Earlier report
“When a prisoner is on an ACCT (Assessment, Care in Custody and Teamwork) and a CSRA (Cell Sharing Risk Assessment) indicates an inmate should be in a cell alone for the protection of others.”
The response stated
“providing clear information for staff and prisoners about the ACCT process and their role in it”
Raised again
5 years 8 months later
“I am concerned in relation to the ability of any Prison to close an ACCT, with the attendance of 2 individuals (a prison and health care staff), after a short period of time on a newly transferred inmate (i.e. to a new prison) before anyone has had the time to review and assess him or her.”
Both reports highlight concerns that the ACCT review process may be insufficient when circumstances change, such as a CSRA indicating solitary confinement or a prisoner transfer. They differ in focusing on policy reminders/training versus procedural safeguards for transfers.
London Ambulance Service · Ambulance service
Lack of shared welfare check guidanceEarlier report
“The MPS and the London Ambulance Service (LAS) have joint working arrangements however the changes made concerning the future handling of welfare checks was not shared with the LAS at that time.”
The response stated
“a Control Services Bulletin will be issued at the 15/89/2015 15:56 62077832889 LAS_LEGAL | PAGE 63/83 end of September 2015 about the MPS welfare checks policy to mitigate the risk of a call to a vulnerable patient being closed prior to assessment by a clinician.”
Stated timescale: end of September 2015
Raised again
6 years 2 months later
“The LAS quality manager accepted in evidence that it would have been better to have taken her number and to pass it on to the police to make contact.”
Both reports highlight a lack of clear, shared guidance between the London Ambulance Service and other agencies (police or GPs) when handling welfare‑check requests, leading to potential gaps in patient safety.
HMP Hewell · Prison or detention
Delayed ACCT case review and documentation failureEarlier report
“(3) Further concerns involved the failure of the nurse to be provided with the ACCT document when Mr [name redacted] was interviewed by her and her further failure to make any entry within that document detailing her professional view.”
The response stated
“Since Mr [name redacted]' death, HMP Bristol has introduced a system whereby their safer custody team contacts the receiving establishment via email and telephone whenever a prisoner on an open ACCT transfers out of the prison to make the receiving establishment aware of the prisoner's perceived risk of harm. In addition, the escort contractors are also now informed of those prisoners on open ACCTs prior to being transferred out to court or other establishments. These conversations are recorded on Prison-NOMIS”
Raised again
8 years later
“that no Initial ACCT Case Review was held within 24 hours of the Concern & Keep Safe form being completed on 21.6.19;”
Both reports highlight failures in the proper use and documentation of the ACCT (Assessment, Care in Custody and Teamwork) process concerning prisoner safety.
Department of Health and Social Care · National body
Inadequate staff knowledge of pressure sore prevention and equipment useEarlier report
“Staff working on mental health wards dealing with elderly patients must have a clear understanding of basic medical care in particular how pressure sores occur and what steps are required to address those at high risk.”
The response stated
“was to write to you again in March 2016 to confirm that all future actions have indeed been delivered.”
Stated timescale: March 2016
Raised again
6 years 1 month later
“once Mr [name redacted] sacral sore had occurred, due to staff inexperience and lack of training, the equipment provided to reduce the further development of his sacral sore was either not utilised, or if utilised sometimes used incorrectly.”
Both reports highlight that insufficient staff training leads to inadequate management of pressure ulcers/sores. The earlier report stresses lack of knowledge about sore formation and prevention, while the later report notes that inexperience results in misuse of preventive equipment.
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust · NHS body
Unclear discharge responsibility and lack of named consultant review prior to paEarlier report
“No clinician took clear responsibility for discharge decision making. The recording of the identity of the discharging clinician was incorrect and communication between clinicians and nursing staff was unclear.”
The response stated
“We have developed a new CDU(Clinical Decision Unit) standard operating procedure, which | attach, where it makes clear where responsibility lies for various aspects of the patient pathway. It also has CDU pathway document that aids the communication between the main hospital department and CDU on admission. This has now been implemented.”
Stated timescale: now
Raised again
2 years 5 months later
“Lack of Named/Responsible Consultant review prior to a child's discharge”
Both reports highlight failures in assigning clear clinical responsibility for decisions affecting patient safety—one concerning adult discharge planning, the other concerning paediatric discharge review.
Care Quality Commission · National body
Inaccurate and inconsistent care plan entries and record keepingEarlier report
“There were concerns that entries contained in Mr [name redacted] care plan were incorrect, including vital information contained on his weight monitoring sheet. Furthermore, the general quality of record keeping was poor.”
The response stated
“We will carry out a further comprehensive inspection within 12 months, to ensure action has been taken and the provider is no longer in breach.”
Stated timescale: 12 months
Raised again
1 year 8 months later
“The record keeping was inconsistent and lacked detail on general wellbeing.”
Both reports highlight problems with the quality and completeness of resident record keeping. The earlier report cites incorrect entries and missing referrals, while the later report notes inconsistent and insufficient detail in records.
Care Quality Commission · National body
Inaccurate and inconsistent care plan entries and record keepingEarlier report
“Failed to keep accurate records.”
The response stated
“We have improved our systems to identify long running adult safeguarding enquiries and take actions to bring them to a satisfactory conclusion. In December 2016 15% of our adult safeguarding enquiries had been in progress for over 12 months. By December 2017 we had reduced this to 4%, despite the number of adult safeguarding enquiries we are undertaking having more than doubled over that period.”
Stated timescale: December 2017
Raised again
3 years 7 months later
“The record keeping was inconsistent and lacked detail on general wellbeing.”
Both reports highlight problems with the accuracy and completeness of patient records.
Leeds City Council · Local authority
Absence of smoke alarms in dwellingEarlier report
“there were no smoke alarms fitted to the property.”
The response stated
“The coroner has reported that there is a risk of future deaths owing to the fact that there were no smoke detectors fitted to the property. A partial re-wire had taken place in 2008, but no hard wired detection equipment installed, as per the existing Electrical Specification (in which hard-wired smoke detectors are only required to be installed as part of a full re-wire).”
Stated timescale: April 2014 to March 2015
Raised again
7 years 5 months later
“there appeared to be no process in place to check premises had heating, running water or smoke alarms and therefore was fit and safe for a vulnerable person to return to”
Both reports highlight the absence of smoke alarms in a dwelling occupied by a vulnerable person. The later report adds that there is no process to verify the presence of alarms (along with heating and water) before allowing return.
Network Rail · National body
Public access to live rail at platform endEarlier report
“(2) The fencing at the scene of Mr [name redacted] death was a low wooden fence which was easy to climb over.”
The response stated
“seriously and has taken additional measures beyond those required by its standards, to install additional meshing and netting at this location to act as an increased deterrent to climbing”
Raised again
2 years 3 months later
“(3) I am concerned that your investigation into, and consideration of, [name redacted]' death did not keep a sufficiently open mind that she may have climbed the boundary fence to access the railway line.”
Both reports highlight the risk of individuals climbing the boundary fence to gain access to the railway line. They concern the same hazard: inadequate fencing that can be easily climbed.
British Transport Police · National body
Cable ties compromising fence integrityEarlier report
“Evidence suggested that some parts of the perimeter fencing were secured with cable ties”
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
5 years 10 months later
“In [name redacted]' case, earlier consideration to the fence boundary being a credible route of access may have led to the fence boundary being improved more quickly after her death.”
Both reports highlight that inadequate perimeter fencing allowed unauthorized access to the railway site. The later report focuses on the need to treat the fence boundary as a credible access route and improve it promptly.