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
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
1 year 9 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 exact same problem: unacceptable delays with patients waiting in ambulances, causing ambulance resources to be unavailable for other calls.
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”
The response stated
“has considered your concems in relation to the following issues outlined in the two notifications: Flyst Regulation 28 Notification Part 1 ~ That not withstanding changes which have been made by both BGUHB and WAST, there remain wholly unacceptable delays with patients belng kept waliing for long periods in ambularices and ambulance resources consequences being unavailable for allocation te other calls as a result of which the risk of future”
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 highlight unacceptable delays causing patients to wait in ambulances, making ambulance resources unavailable for other calls.
Department of Health and Social Care · National body
Lack of psychological therapy for emotional unstable personality disorderEarlier report
“During the course of the evidence it became apparent that mental health in-patients still do not have access to therapy from a qualified Psychologist, despite the fact that this has been raised in previous Regulation 28 PFD Forms.”
The response stated
“The CCG commissioned a new Primary Care Mental Health Pathway during 2016/17, which mobilised in May 2017. The model has been developed to respond to the local population needs, preparing service users to access therapy in order to optimise recovery performance. The service is subject to robust a performance dependent payment framework which provides assurance of performance delivery.”
Stated timescale: May 2017
Raised again
1 year 3 months later
“The inquest heard that whilst he was under the care of the home treatment team there was no access to psychology services.”
Both reports highlight that patients under home treatment teams lack access to qualified psychologist services. The later report adds waiting‑list issues but concerns the same core barrier to psychological therapy.
Department of Health and Social Care · National body
Insufficient inpatient bed capacity leading to delayed discharges and patient harmEarlier report
“there was a national shortage of acute mental health beds necessitating the use of out of county placements for patients requiring hospitalization for their mental health treatment”
The response stated
“We will eliminate clinically unnecessary out of area placements for adult acute mental health care by 2020/21 and will reduce significantly delayed transfers of care.”
Stated timescale: 2020/21
Raised again
2 years 3 months later
“In August 2018 the deceased required inpatient treatment. There were no beds available and as a result he had further episodes of self-harm and suicide attempts.”
Both reports highlight a shortage of acute mental health beds as a safety concern. The earlier report links the shortage to out‑of‑county placements, while the later report links it to unavailable beds leading to self‑harm.
NHS England · National body
Lack of coordinated chronic asthma managementEarlier report
“The care management and treatment of this child during his final year of life with an exacerbations of asthma was centred solely on treating the immediate presentation as an isolated acute event seeking its stabilisation and returning him to the care of his family.”
The response stated
“In 2014 NHS England set up National Paediatric Asthma Collaborative (NPAC)', partly in response to NRAD, to bring together a wide range of clinicians, commissioners and voluntary sector organisations to work together on improving care and support for children with asthma.”
Stated timescale: 2014
Raised again
1 year 10 months later
“The medical management of this child's asthma attacks on the innumerable occasions she presented to her general practice and hospital was centred solely on treating the immediate presentation as an isolated acute event seeking its stabilisation and returning her to the care of her family”
Same coroner as the earlier report.
Both reports highlight that the child's asthma care focused exclusively on treating each acute attack as an isolated event, without addressing the underlying chronic condition or implementing long‑term management plans.
HMP Pentonville · Prison or detention
Duplicate records leading to missing healthcare dataEarlier report
“I am concerned that this does not go far enough to change past practice and ensure that relevant information is shared, in light of the prison staff's lack of access to System One records”
The response stated
“Following the inquest I have reflected and reviewed healthcare processes and there have been discussions within the healthcare team. Going forward we will ensure that the Local Operating Procedures (LOPs) are embedded, with senior management undertaking audits, to ensure that where any relevant risks and triggers are identified, we will share information with the prison in the following ways:- - Update on C nomis - entry to be made by allocated healthcare staff - Update the ACCT document and”
Raised again
1 year 1 month later
“A past spelling error meant that there were two sets of NOMIS prison records for Mr [name redacted]. This meant that there were then two sets of SystmOne healthcare records.”
Both reports highlight problems with accessing complete prisoner health records due to IT/system issues. The earlier report cites lack of access to System One records and infrequent entries; the later report describes duplicate NOMIS/SystmOne records causing missing assessment data.
Earlier report
“The documentation held by Tameside Hospital relating to the second visit was of poor quality .In particular there was a lack of detail around the decision making.”
The response stated
“We would hope that once you have had a chance to consider this further information with respect to documentation within the ED Department you will be reassured that there is clear evidence that there is nota cultural acceptance of poor documentation with the ED Department and that the department, particularly the Senior Consultants, work hard to ensure that all clinicians fully understand their obligations with respect to documentation and where these expectations are not met, that action is taken”
Stated timescale: end of November
Raised again
1 year 1 month later
“The ward was staffed by ward doctors throughout the day but there was no documeniation to suggest communication between the ward doctors and nursing staff in relation to Mr [name redacted] and his deteriorating picture”
Same coroner as the earlier report.
Both reports highlight inadequate documentation that hindered proper clinical communication and decision‑making.
East Midlands Ambulance Service · Ambulance service
Insufficient ambulance resources in specific divisionEarlier report
“I remain very concerned about resource issues for this ambulance service. I raised similar concerns in a Prevention of Future Deaths Report”
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
2 years 7 months later
“The shortage of double crewed ambulances and fast response vehicles in the Northampton Division.”
Both reports highlight insufficient ambulance resources as a risk to patient safety. The later report narrows the concern to a shortage of double‑crewed ambulances and fast response vehicles in a specific division.
Birmingham and Solihull Mental Health NHS Foundation Trust · NHS body
Insufficient nighttime staffing leading to missed healthcare involvement in ACCTEarlier report
“The evidence presented at the inquest confirmed that at night the healthcare wards are staffed by 1 nurse per ward and 1 prison officer who is shared between both wards.”
The response stated
“The night staffing level for HMP. Birmingham was reviewed. when responsibility for its Operation was transferred to G4S, and NOMS is ste that it is acceptable. G4S has chosen to deploy a Prison Custody Officer (PCO) to patro] the healthcare centre at night, and this is beyond the public sector benchmark which would require the use. an Operational Support Grade (OSG) for this purpose. This allows extr: flexibility, as a PCO is trained and authorised to perform additional dutles, such-as to unoch”
Raised again
4 years 3 months later
“No member of the healthcare team was present at any of Mr. [name redacted] ACCT reviews.”
Both reports highlight failures that prevent appropriate healthcare involvement in ACCT processes, putting prisoners at risk. The earlier report cites insufficient night staffing limiting observation capacity, while the later report notes a breakdown in communication that leaves healthcare unaware of ACCT reviews.
Pennine Care NHS Trust · NHS body
Incompatible electronic records hinder mental health information sharingEarlier report
“The inquest heard evidence that the Mental Health Trust had not introduced one IT system across the Trust, which impacted on information sharing between professionals involved in his care;”
The response stated
“we recognise that there are challenges across the service in enabling secure record sharing and there are a number of steps being taken, fed by NHS England.”
Stated timescale: next two to three and a half years
Raised again
7 months later
“On one admission to the acute hospital following an overdose, he was seen by an alcohol worker from the Mental Health Trust. There was no evidence that that worker had checked to see or understand any previous engagements with Mental Health Services.”
Same coroner as the earlier report.
Both reports highlight failures in sharing patient information across mental health services within the same trust. The earlier report cites the absence of a unified IT system, while the later report notes that information from an alcohol worker encounter was not communicated to wider services.
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
3 years 7 months later
“Some Prison staff had not received any cardiopulmonary resuscitation training. Either as part of initial training or any refresher training.”
Both reports highlight a lack of cardiopulmonary resuscitation training among prison staff who have direct contact with prisoners. They concern the same specific hazard—insufficient CPR readiness—and the same mechanism of inadequate training provision.
Earlier report
“(3) 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 5 months later
“Failure in training and post training monitoring for Trust staff and lack of control over training for agency staff using hazardous substances. Failures in supervisory staff in the housekeeping department (particularly those on the fourth floor of the Thomas Kemp Tower) to adhere to their own practices and requirements eg.”
Same coroner as the earlier report.
Both reports highlight failures in communication that compromise patient safety.