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
Avon and Wiltshire Mental Health NHS Trust · NHS body
Missing admission risk assessments and care plan detailsEarlier report
“(1) [heard evidence that there is no documented risk assessment produced at the time of a service user's admission onto Mason Unit. | would ask that you review whether this is still appropriate.”
The response stated
“The adoption of this new paperwork ensures risks are clearly identified for detainees and its success will be evaluated in 3 months.”
Stated timescale: 3 months
Raised again
3 years 2 months later
“1. Care, Risk and Crisis Management plans were not robust enough and failed to contain sufficient information.”
Both reports highlight shortcomings in documenting and using risk-related information for service users. The earlier report notes missing admission risk assessments, while the later report finds care and crisis plans lacking sufficient detail.
Warwickshire County Council · Local authority
Inadequate street lighting at junctionEarlier report
“There are no signs warning pedestrians or cyclists of the dangers of using the road. There are no street lights. The speed limit on the road is 7Omph. There is no barrier or other protective features between the vehicular traffic and pedestrians”
The response stated
“The feasibility study is expected to be completed by the end of September 2014.”
Stated timescale: end of September 2014
Raised again
4 years 6 months later
“that this road is a regular diversion route from the M1 motorway hence periodically, receives usually large volumes of traffic (3) an absence of an illuminated 'single carriageway' warning sign”
Both reports highlight the lack of adequate warning signage on the road as a safety concern. The earlier report notes absent signs warning pedestrians and cyclists, while the later report points out the missing illuminated 'single carriageway' warning sign.
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
9 months later
“Only post and wire fencing at the rallway boundary In this area. The areas on both sides off the tckneild Way, particularly to the west of the railway, are used by dog walkers and others”
Both reports highlight inadequate fencing along the railway boundary that creates a risk of trespass. The earlier report cites insufficient fencing near a scrap metal dealer, while the later notes only post-and-wire fencing in an area used by dog walkers.
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
“we have made progress against key actions which are all identified in the attached action plan”
Stated timescale: 2016-05-05
Raised again
2 years later
“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 numerous occasions following previous inquests.”
Same coroner as the earlier report.
Both reports highlight ongoing delays in patient flow causing ambulance queues and ED congestion.
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 4 months later
“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 numerous occasions following previous inquests.”
Same coroner as the earlier report.
Both reports highlight ongoing ambulance delays affecting patient handover and resource availability.
Betsi Cadwaladr University Health Board · NHS body
Ambulance delays leading to resource unavailabilityEarlier report
“the current practices in place for the handover of patients at an Emergency Department far too often results in wholly unacceptable delays with patients being kept waiting for long periods in ambulances”
The response stated
“incidents. WAST will review the Welsh MPDS codes and accompanying response recommendations (known as the 'DCR' table), with the intention of broadening the current response categories listed above to further distinguish between higher and lower acuity calls”
Raised again
4 years 8 months later
“The issues of ambulance delays/admission to ED/availability of resources/patient flow and the multifactorial problems”
Same coroner as the earlier report.
Both reports highlight ambulance handover delays at the emergency department leading to prolonged waits and reduced resource availability. The later report notes these problems persist despite prior interventions.
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
1 year 4 months later
“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 numerous occasions following previous inquests.”
Same coroner as the earlier report.
Both reports highlight ongoing ambulance delays, ED admission difficulties, resource availability, and patient flow problems described as multifactorial.
Earlier report
“(1) That quad bike riders are not required to wear crash helmets when driving on public roads.”
Raised again
2 years 7 months later
“In light of the pathologist's comments, | am concerned that the absence of any legal requirement for quad bike drivers to wear crash helmets even where such bikes have been legally adapted for road use presents a continuing and potentially avoidable risk of deaths”
Both reports highlight the lack of a legal requirement for quad bike riders to wear crash helmets on public roads. They refer to the same hazard—missing helmet legislation—though the later report adds detail about legally adapted bikes.
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
“The new footbridge railings are at the current industry standard height of 1250mm.”
Raised again
2 years 4 months later
“I am concerned that the railway track is easily accessible to members of the public from this bridge.”
Both reports highlight that the railway track can be accessed by the public from a bridge due to insufficient protective measures. The earlier report notes unimplemented recommendations to restrict access, while the later report describes a low wall and worn path that allow easy entry.
Welsh Ambulance Service NHS Trust · Ambulance service
Ambulance handover delays due to bed shortagesEarlier 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 1 month later
“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 numerous occasions following previous inquests”
Same coroner as the earlier report.
Both reports describe prolonged ambulance waits due to delayed handovers and limited bed availability, tying patient flow problems to resource unavailability.
Welsh Ambulance Service NHS Trust · Ambulance service
Ambulance handover delays due to bed shortagesEarlier report
“That notwithstanding changes which have been made by both BCuHB and WAST, 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
“we have made progress against key actions which are all identified in the attached action plan”
Stated timescale: 2016-05-05
Raised again
1 year 10 months later
“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 numerous occasions following previous inquests.”
Same coroner as the earlier report.
Both reports highlight that ongoing patient flow problems cause delays in the Emergency Department, leading to ambulance back‑ups and unavailable resources.
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
Both reports highlight inadequate fencing or barriers that allow easy access to the railway line. They differ in the earlier focusing on existing disrepair and the later calling for new fencing alongside a footbridge.