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.
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Earlier report
“Staffing within the Mental Health In-reach team impacting the timely undertaking of meaningful and quality mental health assessments.”
The response stated
“Staffing within the Mental Health In-reach team”
Stated timescale: 15 October 2025
Raised again
8 months later
“There is a policy requirement / expectation that a member of the healthcare team should attend all ACCT reviews.”
Both reports highlight problems with ensuring mental health staff are adequately involved in prison care processes. The earlier report cites staffing shortages affecting mental health assessments, while the later report notes failures to meet the policy requirement for mental health team attendance at ACCT reviews.
HMP Woodhill · Prison or detention
Inadequate ACCT case management at HMP WoodhillEarlier report
“(1)During the course of the evidence | was referred to the most recent report from the HM Inspector of Prisons that highlighted "Recommendations made by the Prisons and Probation Ombudsman following previous deaths in custody, such as the need to improve the quality of ACCT case management documentation for prisoners at risk of suicide or self harm, had not been implemented with sufficient rigour.”
The response stated
“The prison is also implementing a system to provide each offender supported through the ACCT process with a designated case manager throughout the period for which the ACCT remains open.”
Raised again
9 years 10 months later
“Concern 11: Repeated systemic concerns at HMP Woodhill Material before the court from oversight and inspection bodies demonstrated that concerns about drugs, safety, violence, self-isolation, observation panel compliance, ACCT weaknesses and welfare monitoring at HMP Woodhill had been identified over time.”
Both reports highlight that weaknesses in ACCT case‑management and related safeguards contribute to ongoing suicide/self‑harm risks at HMP Woodhill.
Earlier report
“The current system for vehicle licensing relies largely upon the self-awareness of a driver and their willingness and\or ability to self-report medical conditions to the DVLA.”
The response stated
“Department will continue to engage with healthcare professionals and their regulatory bodies to understand if there may be circumstances where doctors and health care professionals could be encouraged or supported in notifying the DVLA when appropriate”
Raised again
11 months later
“the expectation that drivers would self-report their conditions (which arises as a matter of legislation) was not being followed.”
Both reports highlight that the licensing system depends on drivers self‑reporting medical conditions to the DVLA. They note that this reliance is insufficient to catch serious conditions, creating a risk of future deaths.
Earlier report
“there is a substantial risk that neither of the conditions will be reported to the DVLA for monitoring.”
The response stated
“The DVLA will continue to work closely with the panel to explore possible options for change to the existing self-declaration system.”
Stated timescale: 8 May 2025
Raised again
11 months later
“the expectation that drivers would self-report their conditions (which arises as a matter of legislation) was not being followed.”
Both reports highlight that drivers with medical conditions are not reliably informing the DVLA, relying on self‑declaration which is failing.
Ministry of Justice · National body
Absence of in-cell automatic fire detectionEarlier report
“Every prison wing is already fitted with an automatic fire detection system for spaces other than for cells.”
The response stated
“The rollout of the automatic fire safety systems nationally relies on a sustained level of investment and on the availability of resources to ensure that there is minimal disruption to the prison regimes. Fire safety systems are costly and complex to install and there can be delays in these works due to important measures to maintain the safety of staff and prison residents and also to maintain the overall security of the prison. It can therefore take a number of years to install the full system”
Stated timescale: 5-7 years
Raised again
4 years 4 months later
“The Ministry of Justice has determined that in-cell automatic fire detection (AFD) is necessary to minimise the risk of harm from fires.”
Both reports highlight the absence of in‑cell automatic fire detection as a fire safety gap. They agree that installing such detectors would reduce risk from prison cell fires.
Department for Transport · National body
Young drivers carrying peer passengers increase collision riskEarlier report
“(1) That [the deceased] was a driver with only 4 months driving experience after passing her driving test;”
The response stated
“the Department has decided to use the introduction of GDL in Northern Ireland as a pilot, to gather evidence on the potential for GDL in Great Britain.”
Raised again
7 years 6 months later
“The driver of the vehicle which crashed was 17 years of age. The three passengers in the car including [the deceased] who died were also under 18.”
Both reports highlight the danger posed by newly licensed teenage drivers carrying teenage passengers, which increases crash risk due to inexperience and peer distraction.
Department for Transport · National body
Young drivers carrying peer passengers increase collision riskEarlier report
“As set out above, the court found that it was possible that the fact that [the deceased] had only just passed his driving test contributed to the collision.”
The response stated
“We will be considering policies relating to young, new drivers during this development.”
Raised again
1 year 10 months later
“I am concerned that when 17 year olds pass a driving test, they can drive on any road in the UK including motorways without any adult supervision.”
Both reports highlight the risk posed by newly licensed teenage drivers who face no additional restrictions or supervision after passing their test. They differ in focus: the earlier report suggests general restrictions on driving times and passengers, while the later report stresses the absence of adult supervision, especially when teens carry peers.
Department of Health and Social Care · National body
Insufficient inpatient bed capacity leading to delayed discharges and patient harmEarlier report
“I heard that a bed on the mental health ward should have been available for Mr [name redacted] when he was discharged from the medical wards but that there is a chronic shortage of mental health beds and not just in London but nationally.”
The response stated
“The number of mental health beds required to support a local population is dependent on both local mental health need and the effectiveness of the whole local mental health system in providing timely access to care and supporting people to stay well in the community, therefore reducing the likelihood of an admission being necessary.”
Stated timescale: 2024/25
Raised again
1 year 4 months later
“There is a long standing and well publicised concern that there are fewer mental health beds than patients who are assessed as needing these.”
Both reports identify a shortage of mental health beds as a risk to life. The later report adds detail about referral thresholds but concerns the same core issue.
Central London Community Healthcare NHS Trust · NHS body
Missing documentation and follow up in district nursingEarlier report
“On 11 December 2019 the GP invited the District Nurses Team and Tissue Viability Nurses Team to attend a meeting at the surgery with the practice clinicians to review unexpected deaths and to discuss this case.”
The response stated
“We have updated our Triaging Standard Operating Procedures to ensure a robust process for the management and response to referrals.”
Raised again
6 years later
“the initial assessment for Mr [name redacted] by the District Nurses did not record his next of kin details or what to do should the district nurse not be able to gain access.”
Both concerns involve failures in documentation and follow‑up processes within the District Nursing service that affect patient safety.
Royal College of Paediatrics and Child Health · National body
Delayed or missing clinical observations in pediatric emergency careEarlier report
“It was difficult for the nursing staff to obtain [the deceased]'s observations because he was so distressed. That was understandable, but because of the long wait in a busy department, it meant that on the fourth attendance [the deceased] did not have a full set of observations for over four hours”
The response stated
“The Trust has ratified and disseminated an updated guideline for recording and escalating physiological observations in children and young people. This includes guidance for staff that the inability to obtain observations should be considered and escalated in the same way as abnormal observations.”
Raised again
1 year 7 months later
“Incomplete documentation to be addressed to include all updates from nursing staff in relation to observations and escalations; and handovers from the medical team to one another to be clearly recorded.”
Both reports highlight problems with ensuring that children's clinical observations are properly obtained, recorded, and acted upon when staff cannot complete them.
NHS England · National body
Unclear wording in NHS Pathways triage questionsEarlier report
“The NHS 111 telephone triage service uses the NHS Pathways computer system to triage patients via pre-determined question/answer based algorithms. The pre-determined questions are the same whether the caller is an adult or a child.”
The response stated
“call handlers receive significant training in questioning and listening skills during initial core training and through ongoing training updates. This is supported and monitored through monthly call audit. This training and on-going monthly call audit are all mapped to the NHS Pathways Competencies.”
Raised again
6 years 10 months later
“Evidence showed that a key NHS Pathways question used during triage was not understood by the caller and did not elicit clinically significant information.”
Both reports highlight that the wording of NHS Pathways triage questions can be unclear to callers, leading to misunderstandings.
Earlier report
“if hospital handover delays didn't exist they would be likely to be meeting their response targets as they did before hospital delays became chronic”
The response stated
“The plan outlined key actions to recover and improve urgent and emergency care services, including: - improving ambulance response times; - increasing ambulance capacity through growing the workforce (for example, increasing clinical capacity in control rooms); - alongside broader system actions to improve flow through hospitals and reducing handover delays; - speeding up discharges from hospitals; - expanding new services in the community.”
Stated timescale: 2023/24
Raised again
1 year 11 months later
“Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought, reducing emergency response capacity during periods of high demand.”
Both reports identify hospital handover delays as a factor that reduces ambulance availability and worsens response times. The later report reiterates that prolonged handover times lead to no ambulance being available when help is sought.