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
Brighton and Sussex University Hospitals NHS Trust · NHS body
Incomplete national early warning system scoringEarlier report
“after a NEWS score of 8, and a medical emergency team call made at about 09:45 on the morning of the 23 February 2015, the scoring is not completed.”
The response stated
“We have carried out a careful review of the medical records with the appropriate personnel.”
Stated timescale: 7 November 2015
Raised again
4 years 4 months later
“(1) Once again | must write concerning the serious failings in the use of NEWS. Please see the Record of Inquest for details.”
Same coroner as the earlier report.
Both reports highlight failures to complete NEWS scoring after a patient's deterioration. They refer to the same specific hazard: incomplete use of the National Early Warning System.
Lincolnshire County Council · Local authority
Insufficient traffic calming at junction leading to collisionsEarlier report
“| was told that since 1985 there had been 4 other fatal road traffic collisions at this junction, two of which involved vehicles turning across Southbound traffic.”
The response stated
“The latest KSI Review which is about to be completed, has identified the A1 near Toll Bar Road as a site that requires prioritisation for closer investigation following the fatal Sye7s fy INVESTORS WF J INPEOPLE ane.”
Stated timescale: during the New Year
Raised again
3 years 1 month later
“The inherent danger of the location arose because of a lack of traffic calming measures such as a reduction of the speed limit at this location”
Both reports highlight the same junction as a dangerous site with a history of near‑misses and fatal collisions. The later report adds that the danger stems from missing traffic‑calming measures such as a lower speed limit and double white lines.
Lincolnshire County Council · Local authority
Insufficient traffic calming at junction leading to collisionsEarlier report
“Alternatively there should be the deployment of considered traffic calming measures (cameras, traffic lights, speed restrictions)”
The response stated
“We would continue to monitor funding opportunities for the roundabout and Z We are currently assessing the impact the traffic calming measures have had on collision rates”
Raised again
9 months later
“The inherent danger of the location arose because of a lack of traffic calming measures such as a reduction of the speed limit at this location”
Both reports identify the same junction as hazardous due to insufficient traffic calming measures. They agree that adding controls such as speed limits, cameras, or road markings would reduce the risk.
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
1 year 11 months later
“Furthermore, the general quality of record keeping was poor.”
Both reports highlight failures in maintaining accurate patient records within care settings.
Earlier report
“There was a failure by the MPS Missing Person's Unit (Greenwich) to carry out an effective search for [the deceased] as a consequence of the lack of information not shared with the Unit”
The response stated
“The means by which the Missing Persons Unit (Greenwich) is able to access essential information in respect of a missing person, in order to carry out an effective prioritisation of resources required for any search”
Raised again
5 years 3 months later
“C&l ward staff did not have a proper understanding of what key information they needed to provide the MPS in order to trigger a police missing person enquiry, or to escalate an existing enquiry.”
Both reports highlight a breakdown in the flow of necessary information to the police that hinders an effective missing‑person response.
Betsi Cadwaladr University Health Board · NHS body
Ambulance delays leading to resource unavailabilityEarlier report
“The issues of ambulance delays/admission to ED/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by me on several occasions following previous inquests.”
The response stated
“In October 2015 WAST introduced a new clinical response model to implement new ways in which callers to 999 are assessed. This sought to ensure that patients and users of the service received the most appropriate care and a response to suit their individual needs.”
Stated timescale: October 2015
Raised again
2 years 5 months later
“Following an inquest which concluded in January 2014 | issued a regulation 28 report in which | expressed concerns regarding the handover of patients at an emergency department which resulted in”
Same coroner as the earlier report.
Both reports highlight ambulance delays caused by emergency department handover issues that render ambulances unavailable for other calls.
Betsi Cadwaladr University Health Board · NHS body
Ambulance delays leading to resource unavailabilityEarlier report
“unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”
The response stated
“In October 2015 WAST introduced a new clinical response model to implement new ways in which callers to 999 are assessed. This sought to ensure that patients and users of the service received the most appropriate care and a response to suit their individual needs. The changes made clearly identify those patients who require an immediate life-saving response and these patients receive the highest priority response in the fastest possible time. foe) All other patients receive a bespoke”
Stated timescale: October 2015
Raised again
2 years 6 months later
“unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”
Same coroner as the earlier report.
Both reports cite the same specific problem: unacceptable delays with patients waiting in ambulances due to handover issues at the emergency department, which ties up ambulance resources.
Betsi Cadwaladr University Health Board · NHS body
Ambulance delays leading to resource unavailabilityEarlier report
“there remain wholly unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls as a result of which the risk of future deaths continues.”
The response stated
“we have made progress against key actions which are all identified in the attached action plan”
Stated timescale: 2016-05-05
Raised again
3 years 2 months later
“unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”
Same coroner as the earlier report.
Both reports highlight unacceptable delays where patients wait in ambulances, making ambulance resources unavailable for other calls. The underlying issue is the same patient flow problem causing these delays.
Earlier report
“Downloading prescriptions only up to 2.30pm each day, with the aim of labelling all prescriptions downloaded on that day.”
The response stated
“An improved reporting mechanism has been developed to record actions and results of the audit and support the ongoing maintenance of the changes which have been implemented.”
Raised again
2 years 1 month later
“The GP issued a prescription to a nominated chemist, but a few minutes later put the system details back to what they were before the prescription was issued.”
Both reports concern failures that prevent a prescription from being downloaded or accessed by the pharmacy. The earlier issue stems from a time‑limited download policy, while the later issue arises from a GP resetting the system after issuing the prescription.
HMP Woodhill · Prison or detention
Inadequate ACCT documentation and healthcare absence during reviewsEarlier report
“(1)During the course of the evidence | was referred to the most recent report from the HM Inspector of Prisons that highlighted”
The response stated
“The prison is also implementing a system to provide each offender supported through the ACCT process with a designated case manager throughout the period for which the ACCT remains open.”
Raised again
3 years 5 months later
“it became apparent during the course of the evidence that ACCT reviews were being conducted on many occasions without someone from Healthcare being in attendance.”
Both reports identify shortcomings in the ACCT (Assessment, Care in Custody and Teamwork) process at HMP Woodhill. The earlier report focuses on inadequate implementation of recommendations to improve ACCT documentation, while the later report notes that healthcare staff are often absent from ACCT reviews.
Association of Ambulance Chief Executives · Ambulance service
Inadequate training for police and ambulance crew on acute behavioural distressEarlier report
“it was clear from the inquest that there was a 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
4 years 7 months later
“During the iInquest evidence was heard that: i. 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.”
Both reports highlight insufficient knowledge about managing acute behavioural disturbance leading to risks during restraint.
NHS England · National body
Inadequate double check in controlled drug auditEarlier 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
1 year 11 months later
“The audit checking of controlled drugs by The Boots Company PLC is not robust in that there is no double check in place in relation to the audit checking procedure followed by Boots”
Both reports highlight weaknesses in the audit and checking procedures for controlled drugs, specifically the lack of a robust double‑check system.