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 for Transport · National body
Insufficient visibility of pedestrians near stationary lorriesEarlier report
“whilst the relevant EU Directives (2003/97/EC and 2005/27/EC) and associated legal requirements for some high-fronted goods vehicles require the fitting of a 'front blind spot mirror' (Class VI) of a certain size, shape and resulting view, the actual shape (convex) and size of such mirrors does not provide sufficient visibility of slow moving pedestrians (especially the elderly)”
The response stated
“will endeavour to explain the current legislation on vehicle construction matters and the steps being taken to address your concerns”
Raised again
5 years 2 months later
“standard class 5 and 6 mirrors create an avoidable risk cab drivers will not see other road users and pedestrians in close proximity to the cab when stationary.”
Both reports highlight that convex front‑blind‑spot mirrors on large goods vehicles do not give drivers adequate visibility of nearby pedestrians, especially the elderly or those in low‑visibility clothing.
Earlier report
“The Out of Hours GP, EE cid not have access to either the mental health or GP records”
The response stated
“implemeented a neww assessmeent service rreplacing the Single Pooint of Acceess to ensure thhat access to mental health serrvices is coonsistent annd effectivee. Each loocality areaa now has a designated rreferral admministrator to manage all referrals into Adult Mental HHealth Servvices and thhe administratoor requests a copy of tthe Patient Profile fromm the patiennt's GP for every referrral receiveed”
Raised again
2 years 7 months later
“the out of hours GP reviewing Miss [name redacted] had no electronic access to her regular GP records”
Both reports highlight that out‑of‑hours GPs cannot access patients’ regular GP records, which hampers safe decision‑making.
Network Rail · National body
Public access to live rail at platform endEarlier report
“Photographs of the location where the death occurred, provided by British Transport Police show that various sections of fencing and walls separating the public footpath from the railway line were broken, missing or in disrepair.”
The response stated
“Network Rail has reviewed the active fencing proposals for upgrade on both sides of the track in the section where the incident occurred and have included these in our 2018 renewals plan”
Stated timescale: 2018 renewals plan
Raised again
3 years later
“There were no physical boundaries at the end of the platform preventing members of the public accessing the railway tracks.”
Both reports highlight insufficient physical barriers that allow public access to the railway tracks, creating a risk of trespass. The earlier report focuses on broken fencing and walls along a footpath, while the later report notes missing boundaries at a platform end.
Network Rail · National body
Public access to live rail at platform endEarlier report
“Recommendations in The BTP Post Fatality Report to create a safer environment”
The response stated
“over At the shoulder of the steps/ramps and the main span there is an anti-climb guard at a greater height than the railings as further mitigation. In addition there is the acoustic fencing and anti-climb wire extensions to prevent anyone accessing the track if they were to climb over”
Raised again
4 years 1 month later
“There were no physical boundaries at the end of the platform preventing”
Both reports highlight insufficient measures to stop members of the public from gaining access to the railway tracks. The earlier report focuses on missing bridge safeguards, while the later report notes absent platform-end boundaries.
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 CCG is working with the Pennine Care NHS Foundation Trust to agree a Performance and Outcome Framework for 2019-20 to ensure activity, waiting times and outcomes are reported and monitored.”
Stated timescale: 2019-20
Raised again
1 year 1 month later
“he was worried about how long it would take him to be able to access appropriate mental health services and receive support.”
Both reports highlight excessively long waiting times for mental health treatment as a safety concern. The earlier report cites an 18‑week target as too long, while the later report describes a person’s anxiety about delayed access to appropriate services.
Earlier report
“the system in place for the administration, documentation and audit of processes associated with the use of controlled drugs”
The response stated
“The policy was updated in November 2017 to include reference to an opioid patch monitoring form. The use of the form should minimise the risk of a similar incident experienced by Mr [name redacted] being repeated. The trust managers have informed the Commission that they plan to audit implementation of the form. We will monitor this through our quarterly engagement meetings and subsequently consider this at the next inspection, which is likely to take place between October and December 2018.”
Stated timescale: between October and December 2018
Raised again
2 years 4 months later
“processes had been such that it was not easily identified that drugs were not accounted for e.g. Stock sheets were inaccurate”
Both reports highlight problems with tracking and accounting for controlled drugs in care settings.
NHS England · National body
Self certification enables unsafe drug accessEarlier report
“Permitting the patient to "self certify" without any checks he can appropriately access this medication can allow the patient fo give inaccurate answers”
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
1 year 6 months later
“Permitting the patient to "self certify" without any checks can allow abuse of the system by those most vulnerable who have addiction problems.”
Both reports highlight that permitting patients to self‑certify for medication without checks enables vulnerable individuals with addiction problems to obtain drugs in unsafe quantities. They also note that allowing patients to opt out of informing their GP removes an important safeguard against misuse.
Earlier report
“There is nothing to prevent pedestrians crossing the carriageway of the bridge (such as a central fence) and neither is there any protection for pedestrians who have reached”
The response stated
“TfL will be carrying out a detailed investigation of the lighting levels and the distribution of light over the bridge by August 2015”
Stated timescale: August 2015
Raised again
5 years later
“I heard at inquest that there is no pedestrian crossing on the A12 near the location of the collision.”
Both reports highlight a lack of protective measures that would prevent pedestrians from being exposed to vehicle traffic while crossing a road. The earlier case concerns missing barriers on a bridge, while the later case concerns a missing marked crossing on an underpass.
Earlier report
“(2) At night the level of street lighting is low, the lamp standards producing pools of light which have the effect of leaving contrasting areas of the carriageway in relative darkness;”
The response stated
“TfL will be carrying out a detailed investigation of the lighting levels and the distribution of light over the bridge by August 2015”
Stated timescale: August 2015
Raised again
5 years later
“I further request that the street lighting between Mountbatten roundabout and Clock Garage Roundabout is reviewed in relation to the amount of lighting and to ensure that the current lighting is working.”
Both reports identify inadequate street lighting creating dark areas that endanger pedestrians.
East Midlands Ambulance Service · Ambulance service
Ambulance resource shortage delays urgent patient transfersEarlier report
“I was advised that EMAS has had to invoke such a Plan (to at least level 3) for 9 out of the last 12 months.”
The response stated
“The need for an urgent review of resources to reduce the risk of future deaths”
Stated timescale: 2016/17 contract
Raised again
3 years 8 months later
“there is a risk of future death if urgent transfers are not available to acutely ill patients due to resourcing issues.”
Both reports identify insufficient ambulance resources as creating a risk that patients needing urgent transfer cannot be moved in time. The earlier report focuses on overall resource shortages and capacity‑management plan usage, while the later report highlights the consequence for urgent transfers of acutely ill patients.
Royal College of Obstetricians and Gynaecologists · National body
Misinterpretation of CTG traces leading to missed abnormal fetal heart rateEarlier report
“It was apparent that the Midwives involved with [the deceased]'s birth and a Junior Obstetrician, appeared not to understand that the cardiotocograph (CTG) trace was abnormal on several occasions.”
The response stated
“in partnership with the Royal College of Obstetricians and Gynaecologists and Health Education England e-Learning for Healthcare developed a comprehensive web-based resource called eFM: an e-learning resource aimed at improving the interpretation of electronic fetal monitoring and subsequent management. This is a free resource for all employees of the National Health Service and contains knowledge-based interactive tutorials, assessments”
Raised again
2 years 11 months later
“There is a risk to the life of both mothers and babies if there is a lack of clarity as to the processes or the need to take prompt action where it is necessitated in the event of an obstetric concern or emergency developing.”
Both reports highlight failures in responding to abnormal cardiotocograph findings during labour. They differ in focus: the earlier stresses training deficits, while the later stresses unclear processes and delayed action.
Earlier report
“Formal mental health act assessment”
Raised again
8 months later
“no-one appeared to have looked at his mental health except to note that he was alcohol dependant”
Both reports highlight failures to adequately assess or address the individual's mental health needs. The earlier report focuses on the absence of a formal Mental Health Act assessment, while the later report notes that no mental health evaluation was performed beyond noting alcohol dependence.