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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Greater Manchester Health and Social Care Partnership · Other
Delayed A&E assessment due to insufficient inpatient bed capacityEarlier report
“Lack of bed capacity in the hospital meant that he spent over 24 hours in the A and E department despite being frail and vulnerable.”
The response stated
“All localities within GM are now in the process of implementing these. In addition to this, further work is being undertaken to help reduce the numbers of attendances to emergency departments. As highlighted in previous correspondence, GM has agreed to a new approach which will incorporate two elements: - Implementation of the new national NHS 111 First Initiative, which will ask patients to call 111 prior to attending an Emergency Department - A new pre-Emergency Department triage and streaming”
Stated timescale: early December
Raised again
8 months later
“It was during the prolonged wait in the Emergency Department for a mental health bed that Mr [name redacted] left.”
Same coroner as the earlier report.
Both reports describe excessive time spent in the Emergency Department because of insufficient inpatient bed capacity. The earlier case involved general acute bed shortages; the later case involved a shortage of mental health beds.
Department of Health and Social Care · National body
Inadequate inter-agency communication about risk and urgencyEarlier report
“As to how that information is shared with other agencies involved in the care of that patient to ensure that it is accurately passed on, particularly as to the level of risk and degree of urgency.”
The response stated
“we are now updating leaflet 2-7-2 of the Department's medical policy document (Joint Service Publication (JSP) 950) which covers the provision and management of Defence mental health services. This will include new guidance and policy on the principles of transfer, which will include addressing both internal transfers of care between different Defence Medical Services (DMS) care providers and the transfers between DMS providers and external agencies.”
Raised again
6 years 2 months later
“there was no clear agreement or arrangement between agencies as to how to effectively share information in complex cases”
Both reports highlight problems with sharing information between agencies regarding the level of risk and urgency of patient care. They concern the same hazard: inadequate inter‑agency communication about risk and urgency.
Cole Valley Care Limited · Company or provider
Inadequate falls risk assessment updateEarlier report
“The current falls Risk Management and Risk Assessment documents (requested by the CQC and CCG) are undated and unsigned and continue to place reliance on the presence of a staff member to prevent falls”
The response stated
“New, comprehensive Falls Risk Assessments (FRAs) for all residents have been introduced and completed. The FRAs consider internal and external risk factors, provide a risk score which then generates a”
Stated timescale: 03rd April 2019
Raised again
2 years 2 months later
“The nursing home manager in her written report 5 to the Coroner stated that [the deceased]'s falls risk assessment had been updated. However, the evidence revealed in fact the falls risk assessment had been created on 30 September upon [the deceased]'s arrival, and had never been updated”
Same coroner as the earlier report.
Both reports concern inadequacies in the falls risk assessment process at the nursing home. The earlier report highlights undated, unsigned assessments relying on staff presence, while the later report shows assessments not being updated after a prior fall.
Sussex Partnership NHS Trust · NHS body
Lack of lead practitioner during transfer leading to lost follow upEarlier report
“There seems to be no facility for the Psychiatrist to be involved in the assessment procedure and indicate a course him or herself. There should be. In any event, no contact was made with the GP and there is apparently no follow up system so no one seems to have picked up”
The response stated
“A further action was a review of the triage function/process to include increased involvement from Consultant [name redacted] and additional members of ATS. All clinical triage meetings have a Consultant [name redacted], lead nurse, and administrator present. Following Mr [name redacted] neues Associate Specialist has been invited to attend the triage meetings on a regular basis.”
Raised again
6 years 3 months later
“Mr [name redacted] was lost to ATS follow up apparently due to inefficient processes and a failure to appreciate the urgent need to appoint a Lead Practitioner for him.”
Same coroner as the earlier report.
Both reports describe patients being lost to follow‑up because the trust lacked adequate processes to ensure contact and review.
Earlier report
“there is a 2.5 mile gap in the emergency refuge areas at this point; b) this section of the M6 is elevated and as such there is no land along the edge of the motorway”
The response stated
“The coroner concluded that there was no evidence of a fault with the vehicle, iliness of the driver, or a hazard in the road which caused the driver to stop in a clearly marked live running lane on a high-speed road. The reason the driver stopped on the M6 motorway was not established "as part of the coronial process.”
Raised again
1 year 5 months later
“absence of a hard shoulder contributed to the collision. Had the [deceased's] vehicle been able to stop in a location other that a live lane, the offending HGV would not have driven into the back of it”
Both reports highlight that insufficient provision of a hard shoulder or refuge area increases the danger when vehicles stop in a live lane on a smart motorway. The earlier report points to a gap in emergency refuge areas and limited verge width, while the later report notes a complete absence of a hard shoulder on an All Lanes Running segment.
Earlier report
“the stretch of motorway in question was raised with a significant drop next to the hard shoulder”
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
1 year 4 months later
“absence of a hard shoulder contributed to the collision. Had the [deceased's] vehicle been able to stop in a location other that a live lane”
Both reports highlight problems with the hard shoulder that prevent drivers from safely stopping in emergencies. The earlier report notes a raised section creating a drop beside the hard shoulder, while the later report notes a complete absence of a hard shoulder.
Earlier report
“1. Is there anyone else with you or are you alone? If there is anyone else with you may | please speak to them.”
The response stated
“Call handlers using NHS Pathways are always trained to speak directly with the patient when it is a 3° party call, this ensures that the questions being asked are answered as accurately as possible to ensure both a safe outcome and that questions are not mis-interpreted through a 3 party.”
Stated timescale: May 2020
Raised again
1 year 11 months later
“The script currently used by NHS Pathways in respect of emergency callers does not positively persuade callers to call someone to be with them, particularly in circumstances where paramedic attendance is delayed due to demands on the service.”
Both reports highlight that NHS Pathways call scripts do not adequately prompt lone callers to seek companionship or inform them they can call someone for support while waiting for an ambulance.
Earlier report
“there is therefore no national register recording the circumstances of these deaths which could then be analysed and learnt from by allergy specialists”
The response stated
“The BSACTI believes that there is a need for 2 distinct registries. The first is a national register for all anaphylactic reactions, that can be contributed to by any health care professional and would provide invaluable data on emerging patterns of reactions and their circumstances and effectively operate as an early warning signal for new risks and highlight specific situations where risk is higher so that they can be actively mitigated. Such a registry already exists in Europe and the Food St”
Raised again
1 year 3 months later
“It would welcome improved appropriate sharing of information on fatalities as they are not routinely notified in a timely manner when there is a report of a fatality by the local authority or coroner.”
Both reports highlight the absence of a national register or reporting system for fatal food allergic reactions, which hinders analysis and prevention.
Department of Health and Social Care · National body
Lack of public access to adrenaline auto-injectorsEarlier report
“generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces.”
The response stated
“We have produced a number of national guidelines using a process accredited by N JCE (National Institute of Care Excellence) and these include the following: I. BSACI Guidelines for the Management or Egg Allergy (20 I0 ) 2. BSACI Guidelines for Diagnosis and Management ofCows Milk Allergy (2014) 3. BSACI Guidelines on Adrenaline Auto-injectors (2016) 4. BSACI Guidelines on the Diagnosis and Management of ul Allergy (2017)”
Raised again
3 years 7 months later
“[the deceased]'s parents have asked that the feasibility of food businesses being issued with AAIs.”
Both reports highlight the lack of readily available adrenaline auto‑injectors in settings where rapid treatment of anaphylaxis is needed.
West Midlands Ambulance Service · Ambulance service
Ambulance fails to document refusal consentEarlier report
“The paramedic asked the deceased's partner to sign the 'non-conveyance' statement on his EPR tablet after summarising a 1 hour 45 minute attendance.”
The response stated
“We are currently in the process of changing the software on our electronic patient report to include a statement that will be visible on the screen where patients, family or carers will see and read prior to signing. This statement clearly sets out that they are signing to acknowledge the refusal for treatment and/or transport to hospital and/or referral for further care against the advice of the attending ambulance clinicians. It also goes on to state that the risks of this has been explained”
Raised again
1 year 1 month later
“(2) The EPR did not record that the deceased had been advised to go to hospital nor that she understood any such advice and she was not asked to sign a disclaimer;”
Both reports highlight that the ambulance service fails to properly document and convey a patient's or family's understanding when refusing hospital transport. The earlier case concerns an unclear signature on a tablet; the later case notes missing records of advice and no disclaimer signature.
Ministry of Defence · National body
Inadequate risk assessment documentation and undocumented risk disclosuresEarlier report
“As to the way in which information obtained from such a patient is recorded , with especial reference to the perceived level of risk and the degree of urgency in carrying out an assessment.”
The response stated
“we are now updating leaflet 2-7-2 of the Department's medical policy document (Joint Service Publication (JSP) 950) which covers the provision and management of Defence mental health services. This will include new guidance and policy on the principles of transfer, which will include addressing both internal transfers of care between different Defence Medical Services (DMS) care providers and the transfers between DMS providers and external agencies.”
Raised again
5 years 9 months later
“His risk assessment was not up-to-date and his disclosures during April were not documented.”
Both reports highlight failures in documenting and communicating risk information about service members with mental health concerns. The earlier report focuses on recording risk level and urgency, while the later report notes an outdated risk assessment and undocumented disclosures.
Earlier report
“lack of record keeping on the Ri O of (i) Risk Assessments and details of those persons making the assessments.”
The response stated
“The Trust has Best Practice and Consistency of Recording on Rio for inpatient services, which includes risk assessments. Within 7 hours of admission, a risk assessment is completed by the admitting nurse and doctor. The time and names of the staff completing the assessment are automatically generated and inputted by the electronic patient record system on Rio.”
Stated timescale: January 2015
Raised again
6 years 3 months later
“Ensure risk assessments are completed for patients going on leave, which identify risks in the community and agreed actions to be taken by staff in case of a breakdown in plan”
Both reports highlight deficiencies in the completion and documentation of risk assessments for patients.