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
Earlier report
“No formal risk assessment was undertaken and staff failed to appreciate what drugs she had available to her.”
The response stated
“We will take action with regards to managing the breach of policy The Senior Nurse for Professional Standards issued a formal practice alert on 12th September 2016 to registered and unregistered clinicians in our crisis and community teams to reinforce the requirements for: Clinical Risk Assessments regarding risk of self-harm and/or suicide; Risk Assessments with regard to medicines management and self-medication; Safe administration of medication as per current Medicines Code and NMC Code.”
Stated timescale: 12th September 2016
Raised again
2 years 8 months later
“(c) no risk assessment was carried out prior to making the decision to return his call bell.”
Both reports highlight that a necessary risk assessment was not performed before a critical decision. The earlier case concerned medication availability, while the later case concerned GP input and call‑bell return.
Earlier report
“(1)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 middle of the carriageway (such as a central reservation);”
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
4 years 1 month later
“(2) There is no pedestrian guard railing at the junction”
Both reports highlight the absence of a physical barrier meant to protect pedestrians from vehicle traffic. The earlier report concerns a bridge lacking a central fence or reservation, while the later report notes a junction without pedestrian guard railing.
Norfolk and Suffolk NHS Foundation Trust · NHS body
Lack of automated discharge medication notification to GPEarlier report
“there is no automated notification to a patient's GP of the type and amounts of prescription medicines issued to a patient upon discharge from Woodlands”
The response stated
“The Trust will make an assessment of the medications prescribed upon discharge and this consideration will continue across the Trust.”
Raised again
2 years 1 month later
“An initial full, updating letter was sent to [the deceased]'s GP. However no further updating information was sent.”
Both reports highlight failures in reliably communicating medication or updating information from the trust to a patient's GP. The earlier report points to missing automated notifications, while the later report describes missed manual updates.
Norfolk and Suffolk NHS Foundation Trust · NHS body
Lack of continuity of care due to excessive care team membersEarlier report
“Although seen regularly by the Crisis Team, Mrs [name redacted] was seen by a number of different people as a result of which no trusting relationship could be established.”
The response stated
“The Trust is planning to review the functions of the CRHT over the forthcoming months. Included within this review will be how we can improve the consistency of staff engaged with the service user. | would like to provide you with an update on progress in early September.”
Stated timescale: early September
Raised again
4 years later
“Miss [name redacted] repeatedly spoke about her concern about the number of people involved in her care, particularly from the Crisis Resolution Home Treatment Team.”
Same coroner as the earlier report.
Both reports highlight that patients were seen by numerous different staff members, preventing a trusting relationship and requiring them to repeat their personal history. This lack of continuity of care is the core concern in each case.
Network Rail · National body
Public access to live rail at platform endEarlier report
“I am concerned that the railway track is easily accessible to members of the public from this bridge.”
The response stated
“Network Rail is planning to apply mitigation measures (wire mesh panels with base plated fence posts fixed to the top of the parapet walls) to the parapet walls to further deter access to the track below. An order has now been placed with Network Rail's framework contractors in respect of these works, with an anticipated completion date of the end of September 2018.”
Stated timescale: end of September 2018
Raised again
8 months later
“The fencing at the scene of Mr [name redacted] death was a low wooden fence which was easy to climb over.”
Both reports highlight that existing barriers are insufficient to prevent public access to the railway line, creating a risk of injury or death from trains.
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
1 year 10 months later
“The fencing at the scene of Mr [name redacted] death was a low wooden fence which was easy to climb over.”
Both reports highlight inadequate fencing or barriers that allow public access to the railway line, creating a risk of trespass and potential harm. The earlier report notes broken, missing, or disrepaired fencing and walls, while the later report describes a low wooden fence that is easy to climb.
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 at the bridge and restrict public access to the railway had not been effected by the time of the inquest.”
The response stated
“We are in the process of installing acoustic fencing on both sides of the track at a height of 3m. This will also have anti-climb wire extensions fitted as an additional deterrent at certain sections.”
Raised again
3 years later
“(1) You have a duty under the Railway Safety (Miscellaneous Provisions) Regulations 1997 to prevent access to the railway line so far as is reasonably practicable. (2) The fencing at the scene of Mr [name redacted] death was a low wooden fence which was easy to climb over.”
Both reports highlight the need to stop members of the public from gaining unauthorised access to the railway line. They differ in the specific context – one concerns a bridge in London, the other a low wooden fence at a station in Cumbria.
Network Rail · National body
Public access to live rail at platform endEarlier report
“The gate is of wooden construction and | provides little deterrence or hindrance to someone wanting to gain access to the railway”
The response stated
“In relation to the wooden gate, this gate will be upgraded by the 2° December 2016, as part of a comprehensive upgrade to the fencing at this site.”
Stated timescale: 2 December 2016
Raised again
2 years 7 months later
“The fencing at the scene of Mr [name redacted] death was a low wooden fence which was easy to climb over.”
Both reports highlight that a wooden fence or gate at the site offers insufficient resistance to prevent unauthorized access to the railway line. The later report notes the same type of barrier remains easy to climb, while the earlier report described the gate as providing little deterrence.
Network Rail · National body
Public access to live rail at platform endEarlier report
“fencing beside the railway track was inadequate especially at the rear of a scrap metal dealer located off St Albans Road and Bedford Street”
The response stated
“in line with this recommendation, an inspection was undertaken by Network Rail's local operations team on 17 May 2017 to establish ownership and condition of the boundary fencing”
Stated timescale: 17 May 2017
Raised again
1 year 2 months later
“The fencing at the scene of Mr [name redacted] death was a low wooden fence which was easy to climb over.”
Both reports highlight inadequate fencing alongside the railway that allows trespassing onto the line. The earlier case concerned a scrap metal dealer site, while the later case involved a low wooden fence at a station location.
Network Rail · National body
Public access to live rail at platform endEarlier report
“Both the gate and | fence provide little deterrence or hindrance to someone wanting to gain | access to the railway”
The response stated
“e We have commissioned works to enhance the fencing and gates in this area. These works will be delivered by 15”
Stated timescale: 15
Raised again
2 years 6 months later
“The fencing at the scene of Mr [name redacted] death was a low wooden fence which was easy to climb over.”
Both reports highlight that inadequate fencing or gates allow easy access to the railway line, creating a trespass risk.
National Highways · National body
Lack of street lighting on A50Earlier report
“(1) The A50 in question does not have street lighting. Street lighting in this area would be beneficial to prevent future deaths occurring.”
The response stated
“Update to the Regulation 28 response from Highways England concerning the death of [the deceased] PURI. C) Detailed investigations will be undertaken on the fatal accidents occurring on the A50 between junction 3 and junction 4 to understand the wider context of the accidents occurring, gathering information pertaining to the highway and its environs.”
Raised again
6 months later
“The low levels of natural light on this section accentuates the present lack of any street lighting on this section of road which may otherwise assist pedestrians with executing a safe crossing during the hours of darkness.”
Both reports highlight that the absence of street lighting reduces safety for pedestrians in darkness. The later report adds considerations of speed limits and local amenities but retains the core lighting concern.
Earlier report
“Handover was incomplete and unhelpful.”
The response stated
“The Trust introduced a new clinical management structure last autumn, a very few weeks before Mrs [name redacted] last admission. The clinical team now managing the acute medical unit have worked tirelessly to introduce a range of changes in order to improve the functioning and quality of the Acute Medical Unit. These incorporate a range of actions relating to the workforce, education, environment, equipment, patient flow, teamwork and communications.”
Stated timescale: last autumn
Raised again
3 years 9 months later
“His discharge documentation which acts as a handover for his Doctors was barely completed and this lack of completion is unacceptable.”
Same coroner as the earlier report.
Both reports highlight failures in providing adequate handover information when a patient moves between care settings.