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
NHS England · National body
Lack of end-of-day verification of dispensed drugsEarlier report
“A mandatory check, by a suitably qualified pharmacist or by a third party, at the end of the day after cashing up on the till, of records of each (prescription only) drug dispensed against the prescription would be a further precaution against a repetition of these circumstances.”
The response stated
“We set standards for registered pharmacies which focus on the outcomes we expect to see in registered pharmacies. We inspect registered pharmacies against the standards and produce reports of our findings.”
Raised again
5 years 8 months later
“There appears to be no physical check of the contents of prescription boxes when carrying out the audit of schedule 2 controlled drugs.”
Both reports highlight insufficient verification steps in pharmacy processes leading to potential medication errors.
Birmingham and Solihull Mental Health NHS Foundation Trust · NHS body
Lack of acute mental health inpatient bedsEarlier report
“availability of acute mental health beds means the most vulnerable people are being cared for in the community with limited resources and care.”
The response stated
“Creation of an urgent care assessment team to concentrate specifically on the assessment of patients who are in crisis. This approach has been piloted and has demonstrated that having an urgent care assessment team improves outcomes for patients at this vulnerable time. The substantive team will be in place by the end of September 2016”
Stated timescale: end of September 2016
Raised again
3 years 2 months later
“a bed could not be found for the Deceased even though he had been assessed and fit for detention. The absence of a bed meant that Mr [name redacted] was not adequately assessed and appropriate treatment could not be given.”
Both reports highlight a lack of available acute mental health inpatient beds leading to inadequate care and increased risk of death.
Home Office · National body
Lack of formal procedure for informing the Home Office when a detainee is placed on ACDTEarlier report
“they had received training and were told not to make a report under Rule 35(2) of the Detention Centre Rules (SI 2001/238) but instead to use the ACDT procedures to monitor suicidal tendencies.”
The response stated
“The Home Office will take steps to ensure that all staff working in IRCs are reminded of the guidance in place, and of their information sharing responsibilities. This will ensure that information on detainees at risk of suicide and self-harm who are being managed under ACDT procedures is shared promptly and appropriately with all relevant parties. The Director of Detention and Escorting Services will write to all parties in IRCs by the end of April 2019 to bring the requirements for sharing information”
Stated timescale: end of April 2019
Raised again
6 months later
“The Consultant [name redacted] psychiatrist did not read the ACDT documents. This puts detainees at risk.”
Both reports highlight failures in the proper use of ACDT procedures to monitor suicidal detainees. The earlier report notes staff were discouraged from making Rule 35 reports and lacked information sharing, while the later report finds staff unaware of or not reading ACDT documents, leading to inconsistent monitoring.
NHS England · National body
Lack of meaningful family involvement in care processEarlier report
“The meaningful involvement of families in the ACCT process, including by ensuring the formal recording, and communication of concerns raised by a prisoner's family.”
The response stated
“The following information describes the commissioning arrangements for healthcare for someone being held in police custody.”
Raised again
2 years 6 months later
“There was no involvement of the family and so a source of important information was missed.”
Both reports highlight the lack of family involvement in the care process as a safety concern. The earlier report focuses on the ACCT process in prison settings, while the later report notes missed family input in general healthcare provision.
Network Rail · National body
Public access to live rail at platform endEarlier report
“The absence of an end of platform barrier and the existence of a live rail at ground level that might be accessible to members of the public”
The response stated
“In your report, you state that”
Stated timescale: by the end of 2018 with some being finished in early 2019
Raised again
1 year later
“found that [the deceased] died instantly as a result of electrocution when he came in contact with the electric rail at 0557 hrs on the 23 December, 2018.”
Both reports highlight the danger posed by exposed live rails at ground level that can cause electrocution. The earlier report stresses the lack of a physical barrier, while the later report calls for better signage to inform the public about the rail's presence.
Earlier report
“When the deceased is visited and checked all such visits should be | accurately recorded on the custody record”
The response stated
“We already have a process that checks custody records to ensure visits are timely and carried out in accordance with the sergeant's risk assessment”
Raised again
5 years 6 months later
“The Custody Sergeant did not open a custody record immediately on [the deceased] } Harris's arrival in the custody office. He used a piece of paper to record the”
Both reports highlight problems with how custody records are created and maintained, specifically regarding timely and accurate recording of detainee information.
Black Country Partnership NHS Foundation Trust · NHS body
Delayed patient location despite police assistanceEarlier report
“there were deficiencies in the systems in place for contacting and finding the patient. In this case the patient had contacted the CHTT with a real and immediate risk of self harm”
The response stated
“The Trust processes, including the function and service provided by CHTT, are currently under review as part of a wider mental health strategy review. This is taking place in order to modernise services, improve quality of care and access to services. This review will also ensure a seamless service across both the adult and older adult population. The plan is to implement agreed changes to the current system by April 2015.”
Stated timescale: April 2015
Raised again
4 years 9 months later
“Following his release from custody on the 28th September 2018 and evidence from a psychologist that he was threating suicide and harm to others, on the 2nd October 2018 the HTT's only recorded attempt to contact Mr. [name redacted] before the 9th October 2018 was a single call”
Both reports highlight failures in the trust's systems to contact and locate patients who are at risk of self‑harm after discharge or release. The core issue is inadequate communication and contact procedures that delay identification of worsening risk.
Earlier report
“The A285 is an ancient rural road and it does not meet the design standards of a modern road.”
The response stated
“the County Council does not consider there to be any grounds to carry out any works to extend the area of asphalt surface further into the bridleway. The”
Raised again
4 years 5 months later
“There is a speed limit sign approximately 350 metres back from the bend as you travel south.”
Both reports identify safety deficiencies on the A285 rural road that increase collision risk. The earlier report focuses on inadequate road surface and visibility at a farm entrance, while the later report calls for improved signage and overall road improvements.
His Majesty's Prison and Probation Service · National body
Lack of basic first aid training and CPR among prison officersEarlier report
“Some Prison staff had not received any cardiopulmonary resuscitation training. Either as part of initial training or any refresher training.”
The response stated
“The Governor at HMP New Hall has reviewed the band/grade and number of staff who need to be trained in first aid, and the number of such staff required on duty at times throughout the day. The prison currently has 40 staff trained in FAW and 48 in EFAW, and these numbers are considered to be sufficient to ensure that an appropriate response can be provided in any emergency situation that may arise at any time.”
Raised again
8 months later
“One frontline prison staff member gave evidence that he had not received training in 16 years of working for HMPS and felt he needed refresher training.”
Both reports highlight insufficient training of prison staff in life‑saving skills. The earlier report focuses specifically on missing CPR training, while the later report notes a lack of recent first‑aid/refresher training.
His Majesty's Prison and Probation Service · National body
Lack of basic first aid training and CPR among prison officersEarlier report
“Action is required to ensure that Prison Officers and Staff with direct access to prisoners have basic first aid training, CPR training and familiarisation with the use of a defibrillator.”
The response stated
“all but two of the CMs at the prison have been trained, and those two members of staff will be provided with training as soon as they return to duty. HMP Coldingley also uses a monthly closedown of the prisoner regime to provide opportunities for training for the wider staff group and this includes instruction on CPR and on the use of defibrillators.”
Stated timescale: as soon as they return to duty
Raised again
4 years 3 months later
“Prison staff are often first responders to medical emergencies of prisoners, but not all have received first aid training.”
Both reports highlight that prison staff who may be first responders lack adequate first aid training, including CPR and defibrillator familiarity.
East of England Ambulance Service · Ambulance service
Insufficient ambulance availability leading to delayed emergency responseEarlier report
“Consistently high levels of outstanding emergency calls and waiting times that far exceed the service's own target response times are likely to put lives at risk.”
The response stated
“we have introduced a process which instigates the release of ambulance crews from queues in A and E departments to attend to patients in the community with life threatening conditions.”
Raised again
2 years 6 months later
“The amount of time taken for the ambulance to arrive which was markedly outside the Trust's guidelines.”
Both reports highlight that excessive delays in ambulance response—whether due to high outstanding calls or prolonged arrival times—pose a risk to patient safety.
Department of Health and Social Care · National body
Inadequate allergy action plan communication in schoolEarlier report
“The school nurse had updated [the deceased]'s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma).”
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
2 years later
“The allergy action plan drafted by [the deceased]'s doctors at Ealing Hospital did not find its way to his school.”
Both reports highlight problems with the allergy action plan not being correctly applied or communicated in the school setting, leading to inadequate emergency response.