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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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
10 years 11 months later
“The Governor of the prison told the court that no refresher CPR training had been provided to prison staff since 2023 notwithstanding the 5 deaths of prisoners by ligature suspension that have occurred since.”
Both reports highlight the lack of adequate CPR/refresher training for prison officers who are first responders in emergencies. The later report notes that no refresher training has been given since 2023, continuing the same concern.
His Majesty's Prison and Probation Service · National body
Lack of basic first aid training and CPR among prison officersEarlier report
“Evidence was heard that the majority of those prison officers who had commenced in their roles prior to 2018 had no first aid/basic life-saving skills and no ability/training in undertaking cardiopulmonary resuscitation ('CPR').”
The response stated
“attention. The HMPPS First Aid Policy Framework was re-issued nationally in August 2023. The revised policy highlights the training requirements for Emergency First Aid and First Aid in prisons, including the importance of Governors ensuring that there is an appropriate number of trained staff on duty at all times. To achieve this, a detailed local first aid risk assessment must be produced to determine the number of First Aiders at Work (FAW) and Emergency First Aiders at work (EFAW) required at an”
Stated timescale: August 2023
Raised again
1 year 4 months later
“The Governor of the prison told the court that no refresher CPR training had been provided to prison staff since 2023 notwithstanding the 5 deaths of prisoners by ligature suspension that have occurred since.”
Both reports highlight the absence of CPR/refresher training for prison officers as a critical gap in emergency response. They describe the same mechanism—lack of training leading to inability to provide life‑saving aid.
Association of Ambulance Chief Executives · Ambulance service
Inadequate training for police and ambulance crew on acute behavioural distressEarlier report
“lack of understanding of how to treat someone with an acute behavioural disturbance”
The response stated
“We have made a recommendation to the National Education Network for Ambulance Services leads (NENAS) that each trust considers including, if not completed already, the education of front line staff and control room staff in acute behavioural disturbance to raise awareness of the condition and how it can present in a patient.”
Stated timescale: November 2015
Raised again
10 years 10 months later
“in some ambulance localities the required response is allocated Category 2 and in others Category 1. This means that there is not a national standard for response Acute Behavioural Disturbance with active restraint.”
Both reports address inconsistent handling of acute behavioural disturbance across ambulance services.
Earlier report
“the Consultant [name redacted] who reviewed the Deceased on Aspen Ward made the assumption that concern about the Deceased's capacity were raised in the context of her withdrawal from alcohol.”
The response stated
“During [the deceased]'s admission to Aspen Ward, there was not enough consideration of [the deceased]'s historical mental health diagnoses, contextual clinical information from previous inpatient admissions and community care and her overall complexity. There is evidence of the MDT completing an assessment of [the deceased]'s mental health and associated risks over the course of her admission to Aspen Ward.”
Stated timescale: 21/01/22
Raised again
3 years 2 months later
“In respect of findings made in relation to the care provided on the day before [the deceased]'s death, it remains unclear even after hearing all of the evidence how the investigators concluded (at page 24 of 44) '[t]here was no reason to doubt [the deceased]'s capacity at this stage'”
Both reports criticize the Trust's assessment of a patient's capacity, noting that clinicians overlooked relevant contextual information and drew premature conclusions.
Earlier report
“There does not appear to be a formalised decision-making process in place involving both Trusts to review the treatment plan to determine the optimum medical and psychiatric care to suit the particular patient's needs.”
The response stated
“The joint SOP which is scheduled to be trialled in August 2020 will apply to all patients within PCFT's older peoples' mental health inpatient wards. Both organisations will continue to work in partnership to identify, agree and establish working parameters for the Digital Health Team at TGH to support the physical health needs of older people receiving mental health care and treatment on Summers & Hague wards, of which Mr [name redacted] was a patient. The offering of Digital Health services will be conducted”
Stated timescale: August 2020
Raised again
5 years 9 months later
“The investigation does not undertake any meaningful critical analysis of the decision- making process which resulted in her section being rescinded and her therefore being discharged notwithstanding family concerns in circumstances where no s17 leave had first been trialled”
Both reports highlight deficiencies in decision‑making processes concerning patient care and discharge planning. The earlier report cites missing formal cross‑trust review, while the later report notes inadequate analysis of internal discharge decisions.
Earlier report
“There is a lack of inpatient beds leading to unacceptable wait times in A&E for those suffering with their mental health who are awaiting beds.”
The response stated
“I expect individual trusts and local health systems to effectively assess and manage bed capacity, the 'flow' of patients being discharged or moving to another setting.”
Raised again
1 year 1 month later
“The lack of beds, locally and nationally, for mental health admissions and the suggestion given in evidence that patients can be waiting in the open reception area for days or sometimes weeks for a bed.”
Both reports highlight a shortage of mental health inpatient beds causing patients to wait extended periods in unsuitable settings. The earlier report cites A&E waits, while the later report notes waits in an open reception area.
Care Quality Commission · National body
Inaccurate and inconsistent care plan entries and record keepingEarlier report
“There were concerns that entries contained in Mr [name redacted] care plan were incorrect, including vital information contained on his weight monitoring sheet. Furthermore, the general quality of record keeping was poor.”
The response stated
“We will carry out a further comprehensive inspection within 12 months, to ensure action has been taken and the provider is no longer in breach.”
Stated timescale: 12 months
Raised again
6 years 1 month later
“That there remain potential issues of poor record keeping.”
Both reports highlight problems with inaccurate or incomplete care‑plan records and overall poor record‑keeping practices.
Care Quality Commission · National body
Inaccurate and inconsistent care plan entries and record keepingEarlier report
“(1) The record keeping was inconsistent and lacked detail on general wellbeing.”
The response stated
“The provider has indicated they have also reviewed the quality of their own documentation and care records. In relation to food records, in addition to improved documentation, staff have also received additional training.”
Raised again
4 years 6 months later
“That there remain potential issues of poor record keeping. ii) There are concerns over the level of compliance of care plans”
Both reports highlight problems with record keeping, specifically inconsistency and lack of detail in documenting residents' wellbeing and care.
Care Quality Commission · National body
Non‑compliance with care plans and insufficient incident reviewEarlier report
“Failed to follow the advice of the tissue viability nurses as to turning and how to dress Mr [name redacted] sores”
The response stated
“We have improved our systems to identify long running adult safeguarding enquiries and take actions to bring them to a satisfactory conclusion. In December 2016 15% of our adult safeguarding enquiries had been in progress for over 12 months. By December 2017 we had reduced this to 4%, despite the number of adult safeguarding enquiries we are undertaking having more than doubled over that period.”
Stated timescale: December 2017
Raised again
8 years 1 month later
“There are concerns over the level of compliance of care plans.”
Both reports highlight failures to properly implement and document care plan recommendations.
Care Quality Commission · National body
Non‑compliance with care plans and insufficient incident reviewEarlier report
“The inquest heard evidence that because Mrs [name redacted] was in a care home setting the District Nurses were responsible for management of her pressure ulcers.”
The response stated
“Whenever a District Nurse attends a resident at Stable Steps any advice in relation to the management of pressure ulcers is shared with the team via a Communication Book.”
Raised again
1 year 11 months later
“ii) There are concerns over the level of compliance of care plans.”
Both reports highlight problems with how care plans are documented and shared between district nurses and care home staff. The earlier report focuses on non‑sharing of digital care plans, while the later report notes ongoing concerns about care plan compliance and record keeping.
Earlier report
“The ambulance service was called again at 23.45 hours and the call was again coded as a Category 3 call.”
The response stated
“we published our 'Delivery plan for recovering urgent and emergency care services' which aims to deliver sustained improvements in waiting times, including to reduce Category 2 response times (including for serious conditions such as heart attacks and strokes) to 30 minutes on average this year”
Stated timescale: this year
Raised again
2 years 4 months later
“An ambulance should have reached [the deceased] within two hours but it took five and half.”
Both reports highlight delays in ambulance response for Category 3 calls caused by excessive demand and limited resources. The earlier case involved a >14‑hour wait, while the later case describes a 5.5‑hour wait despite targets.
Earlier report
“The RCA was insufficient and did not address all of the issues surrounding Mrs [name redacted] care”
The response stated
“We acknowledge the unacceptable delay in dealing with the pressure sore. We note that category 2 pressure damage was first documented in Mrs [name redacted] health records on 20 September 2022, ten days before the referral to the TVN. In order to strengthen the approach regarding managing pressure sores, the Tissue Viability Team are supporting the ward to undertake a quality improvement (QI) project in relation to the prevention and management of pressure ulcers including the recognition of potential”
Stated timescale: 20 September 2022
Raised again
1 year 8 months later
“Poor management of [the deceased]'s pain. In spite of sustaining a category 2 pressure sore and bilateral hip fractures whilst an in patient at EDGH, he was only receiving oral paracetamol.”
Same coroner as the earlier report.
Both reports highlight problems with the identification and management of pressure sores in patients under the trust's care. The earlier report notes inadequate root‑cause analysis and documentation, while the later report describes worsening of a sore due to poor pain relief and monitoring.