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
Care Quality Commission · National body
Delayed mental health bed allocation leading to patient deteriorationEarlier report
“MHSC say that following the death of the deceased, a new policy has been introduced so that there is no waiting time at all for the allocation of a bed”
The response stated
“A revised governance process has been developed within the Citywide Commissioning, Quality and Safeguarding Team and the Trust now attends an established Citywide Patient Safety Committee. This committee meets monthly and is responsible for the review and monitoring of serious incidents requiring investigation reported by the Trust as well as any other patient safety related issues including those highlighted at inquest via Prevention of Future Death Reports.”
Raised again
2 years 8 months later
“The CCG should review urgently its commissioning of in-patient mental health beds so as to ensure, in so far as reasonably practicable, that a bed is available when a person who satisfies the criteria for a Mental Health Act Assessment needs to be detained following that assessment.”
Both reports highlight the risk that patients needing inpatient mental health care experience delays or cannot get a bed when required. They both call for systemic action to guarantee bed availability at the point of need.
Department of Health and Social Care · National body
Chest drain insertion without pre-procedure checksEarlier report
“Mr. [name redacted] was not examined prior to the insertion of the chest drain.”
The response stated
“we will ensure particular attention is attached to correct site location at the next review.”
Stated timescale: next review
Raised again
1 year 11 months later
“given the evidence that the deceased would not have died when he did but for the drain”
Both reports highlight risks associated with chest drain insertion when proper pre‑procedure checks are omitted. The later report focuses on the drain’s contribution to death and suggests imaging could mitigate the risk, while the earlier report stresses missed examinations and labeling errors.
Pennine Acute Hospitals NHS Trust · NHS body
Incomplete and inaccurate nursing records and documentationEarlier report
“During the course of the inquest hearing it became apparent that the nursing tools (in particular, the 'Purpose T'), assessments, records, associated documentation and nursing discharge summary were incomplete and/or inaccurate.”
The response stated
“We are undertaking a review of current documentation to ensure it meets all Trust standards and therefore supports improvements in care delivery. On a monthly basis the ward is audited using the nursing metrics which includes the quality of record keeping.”
Stated timescale: July 2015
Raised again
1 year later
“Staff did not follow the Trust's protocols/guidance and did not document their rationale where - they exercised clinical discretion”
Same coroner as the earlier report.
Both reports highlight failures in nursing/midwifery record keeping and documentation. The earlier report focuses on incomplete/inaccurate nursing tools and assessments, while the later report cites staff not documenting their rationale and inadequate communication/handover.
Department of Health and Social Care · National body
Lack of antenatal screening for group B streptococcusEarlier report
“That antenatal screening for GBS is not routinely offered by the NHS, to all pregnant women, during the final weeks of pregnancy.”
The response stated
“The UK NSC will be reviewing the evidence for antenatal screening for GBS again in 2015/16 as part of its routine evidence review process.”
Stated timescale: 2015/16
Raised again
1 year 2 months later
“That antenatal screening for GBS was not being routinely offered by the NHS to all pregnant - women during the final weeks of pregnancy”
Same coroner as the earlier report.
Both reports highlight that antenatal screening for group B streptococcus (GBS) is not routinely offered to all pregnant women during the final weeks of pregnancy. They describe the same specific hazard and the same mechanism of potential harm to babies.
Earlier report
“During the inquest evidence was given that ambulance availability is being jeopardised by crews being delayed at hospital when handing patients over to Accident and Emergency staff”
The response stated
“We will be meeting with NEAS in September 2015 to discuss and monitor how they are managing their delivery of the service, what is their current position of staffing levels and identified vacant posts and their current recruitment position.”
Stated timescale: September 2015
Raised again
1 year later
“Consideration should be given to strategies to improve handover times at hospitals.”
Both reports identify delayed patient hand‑over at hospitals as a factor that jeopardises ambulance availability. The earlier report focuses on crew delays during hand‑over, while the later report calls for strategies to improve handover times.
Earlier report
“The consideration of, contribution to and preparation involved in risk care planning for Mr [name redacted] was insufficient in its scope and depth”
The response stated
“we have since revised the documents clinicians are asked to complete. This is to ensure they are less repetitive and better support succinct recording of relevant issues. Regular audits are completed to ensure adequate standards are met.”
Raised again
2 years 3 months later
“The amending and updating of these plans, particularly the Risk Assessment by the relevant members of clinical and nursing staff”
Both reports highlight shortcomings in the creation, updating, and communication of risk assessment and care planning documents. They differ in that the earlier report focuses on insufficient depth and lack of review, while the later report stresses the need for proper amendment, updating, and multidisciplinary communication.
Earlier report
“once the X-ray was performed, the result was not seen by medical staff for over 24 hours”
The response stated
“We have made a number of changes to the handover process, both in relation to medical and nursing procedures.”
Raised again
1 year 3 months later
“There was a delay of 5 days in the formal reporting of the original X-ray;”
Same coroner as the earlier report.
Both reports highlight delays in ensuring that X‑ray results are reviewed and formally reported in a timely manner. The earlier case notes a >24‑hour gap before staff saw the result, while the later case describes a five‑day delay in formal reporting.
Hammerson Plc · Company or provider
Insufficient barriers on elevated structures allowing jumpsEarlier report
“Falls from the car parks have been into areas where the public use pavements and there is clearly a risk of death to pedestrians also.”
The response stated
“We have installed a red wall sensor which is a light sensor which detects individuals accessing the car parks”
Raised again
11 months later
“The wall is easy to access and at least two previous deaths have occurred in similar circumstances since 2006.”
Both reports highlight that insufficient barriers on elevated structures allow people to jump, posing a risk of fatal falls.
Warwickshire County Council · Local authority
Inadequate street lighting at junctionEarlier report
“There are no street lights. The speed limit on the road is 7Omph.”
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
1 year 1 month later
“| was concemed that street lighting was not present at this junction”
Both reports highlight the absence of street lighting as a safety concern for pedestrians and cyclists. The earlier report focuses on a stretch of the A444 road, while the later report concerns a specific junction lacking lighting.
Greater Manchester Police · Police
Delayed risk assessment documentation and missing exit assessments for self-harmEarlier report
“Risk assessments carried out whilst in police custody should be recorded when they are done.”
The response stated
“Since the death of Mr [name redacted], Custody Branch has significantly upgraded its ICIS computer system. This system prompts Custody Sergeants to undertake further reviews linked to specific/significant events affecting the detainees period of detention, including an exit risk assessment”
Raised again
1 year 3 months later
“It was therefore decided to hold a joint medical and police exit risk assessment when someone who has displayed self- harm ideation or behaviour leaves custody”
Same coroner as the earlier report.
Both reports highlight shortcomings in how risk assessments are managed during police custody. The earlier report stresses the need to record assessments promptly, while the later report calls for a joint medical‑police exit assessment for detainees showing self‑harm.
National Police Chiefs' Council · National body
Lack of dedicated substance misuse team in police custodyEarlier report
“That was no dedicated substance misuse team available to look after Mr [name redacted] when he was in the custody suite at Hatfield Police Station, as there would have been had Mr [name redacted] been detained in prison”
The response stated
“The responsibility for healthcare in police custody suites will however soon transfer from individual police authorities to NHS England. Healthcare for persons in police custody will therefore be commissioned to NHS standards of care. This should lead to more consistent and improved healthcare standards, by ensuring that the same range and quality of substance misuse services are available to persons in police custody as would be available in prison or community settings.”
Raised again
1 year 3 months later
“That training should include targeted training on the risks and dangers of drug and alcohol abuse, including methadone intoxication and alcohol withdrawal, particularly if the detainee is likely to be in custody for upwards of 24 hours.”
Both reports address insufficient handling of substance‑misuse issues among detainees in police custody. The earlier report calls for a dedicated substance‑misuse team comparable to prison care, while the later report requests targeted training on drug and alcohol risks.