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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Practice Plus Group · Company or provider
Inadequate ACCT training and knowledge gapsEarlier report
“there was little understanding of the requirement to complete or review the care plan and support actions at every ACCT review not just the planned reviews;”
The response stated
“We have carefully considered the potential for implementing changes to SystmOne to include a tick-box to confirm the review of the care plan and support actions.”
Raised again
1 year 1 month later
“- the ACCT process was not managed and implemented properly, e.g. supervising officers did not consistently acquaint themselves with case notes or history when completing reviews;”
Both reports identify shortcomings in ACCT-related training and knowledge among prison staff. The earlier report cites a lack of understanding of ACCT review requirements, while the later report notes expired ACCT training and over-reliance on a single presentation.
Practice Plus Group · Company or provider
Delayed ACCT case review and inadequate process managementEarlier report
“(a) that no Initial ACCT Case Review was held within 24 hours of the Concern & Keep Safe form being completed on 21.6.19;”
The response stated
“The end date for the acceptance of paper referrals is 31st October 2021. From 1st November 2021, paper TAGs (Threshold Assessment Grid)1 will cease to be an option for referrals to the mental health team.”
Stated timescale: 31st October 2021
Raised again
4 years 4 months later
“the ACCT process was not managed and implemented properly, e.g. supervising officers did not consistently acquaint themselves with case notes or history when completing reviews;”
Both reports highlight failures in the management and implementation of the ACCT process, particularly regarding timely reviews and proper documentation.
Earlier report
“That there is no apparent system for staff to alert odd behaviour and then track an individual of concern on CCTV”
The response stated
“LU station staff receive initial training and ongoing refresher training through our competency management system (CMS) to assist in identifying 'unusual' customer behaviour.”
Stated timescale: immediate effect
Raised again
6 years 8 months later
“Recommended technological measures to detect and alert staff to the presence of persons on the tracks have not been implemented at Stratford station.”
Both reports concern the lack of effective detection of persons on or near railway tracks/platforms. The earlier report focuses on staff noticing odd behaviour and tracking via CCTV, while the later report calls for technological detection of people on the tracks.
His Majesty's Prison and Probation Service · National body
Lack of certified safer cells outside segregation unitEarlier report
“The final area of concern is the lack of certified Safer Cells at HMP Winchester. The inquest heard evidence that these had either never existed at HMP Winchester or had not done so for many years.”
The response stated
“The final concern raised relates to ligature points in cells. HMPPS is currently undertaking a review of ligature-resistant cells, which have been designed to eliminate ligature points as far as possible.”
Stated timescale: too early to say
Both reports highlight the insufficient availability of safer/ligature‑resistant cells for prisoners at risk of self‑harm. The earlier report notes a general lack of certified safer cells at HMP Winchester, while the later report points out that the existing safer cells at HMP Hewell are confined to the segregation unit.
His Majesty's Prison and Probation Service · National body
Lack of certified safer cells outside segregation unitEarlier report
“There is no mandatory requirement for a HMP Prison to have access to a Safer Cell (one with reduced ligature points).”
The response stated
“We recognise that prisoners may feel vulnerable during their time in custody and HMPPS uses the Assessment, Care in Custody, Teamwork (ACCT) case management approach to support people at risk of self-harm and suicide. As part of any case review, those present will consider a range of measures to mitigate risk, including the prisoner's location and whether any possessions need to be removed or returned, and this may include moving the prisoner to a cell that is more appropriate to manage their risk”
Raised again
2 years later
“as long as "safer cells" are not made available away from the segregation unit at the HMP Hewell, an important measure for reducing the risk of suicide or self-harm is being withheld from vulnerable prisoners at that prison.”
Both reports highlight that prisoners at risk of self‑harm do not have adequate access to safer cells designed to reduce ligature points. The earlier report notes a nationwide lack of mandatory safer cells, while the later report observes that existing safer cells are confined to the segregation unit.
Earlier report
“The new Governing Governor confirmed that further steps are necessary to improve the management of illicit substance misuse. He confirmed the prison requires CCTV on all wings and airport style scanners - one in reception for prisoners and one in the visitor area.”
The response stated
“G4S does agree with Mr [name redacted] that HMP Birmingham would benefit from CCTV and airport style scanners. It is G4S's understanding that Mr [name redacted] submitted to HMPPS a case for funding in respect of the cost of purchase and installation of CCTV and that this has been approved. The CCTV will therefore be installed at HMP Birmingham in due course.”
Stated timescale: in due course
Raised again
6 years 11 months later
“The availability of illicit substances continued to be a serious concern that undermined safety and stability. The rate of positive drug tests remained as high as at our full inspection in 2023”
Both reports highlight the ongoing problem of illicit substance misuse within prisons and its impact on safety and stability.
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 7 months later
“The inquest noted that newly qualified drivers may carry multiple peer-age passengers immediately after passing their test.”
Both reports highlight risks posed by young, newly qualified drivers, specifically the danger of carrying passengers soon after obtaining a licence. They differ in focus: the earlier report stresses the need for timing and passenger restrictions, while the later report points out that current licensing does not address peer‑age passenger carriage.
Department for Transport · National body
Young drivers carrying peer passengers increase collision riskEarlier report
“where an inexperienced driver has a distraction of another young person in the car this can increase their risk of having an accident.”
The response stated
“my Department is developing the first road safety strategy in over a decade and will set out more details in due course.”
Raised again
9 months later
“newly qualified drivers may carry multiple peer-age passengers immediately after passing their test.”
Both reports highlight the risk posed by allowing new drivers to carry young or peer‑age passengers shortly after obtaining their licence. They differ in the timing emphasized (within six months versus immediately after testing) and the specific wording of the concern.
Department for Transport · National body
Young drivers carrying peer passengers increase collision riskEarlier report
“Currently there are no legal restrictions upon the licences of young and /or newly qualified drivers and the current vehicle licensing regime permits the carrying of young persons as passengers in circumstances such as these”
The response stated
“we are exploring options to tackle the root causes of this without unfairly penalising young drivers”
Raised again
11 months later
“newly qualified drivers may carry multiple peer-age passengers immediately after passing their test”
Both reports highlight that newly qualified drivers face no legal limits on carrying peer‑age passengers, which increases crash risk. The later report adds detail about inexperience and vehicle dynamics but concerns the same core issue.
Department for Transport · National body
Young drivers carrying peer passengers increase collision riskEarlier report
“Currently, there are no legal restrictions upon the licences of young and/or newly qualified drivers and the current vehicle licensing regime permits the carrying of young persons as passengers in circumstances such as these.”
The response stated
“My Department is developing our road safety strategy and will set out more details in due course.”
Stated timescale: due course
Raised again
1 year 2 months later
“newly qualified drivers may carry multiple peer-age passengers immediately after passing their test.”
Both reports highlight the risk of deaths when newly qualified or young drivers carry peer‑age passengers shortly after passing their test. They identify the absence of licensing restrictions or training addressing passenger‑related risks as the shared concern.
His Majesty's Prison and Probation Service · National body
Lack of certified safer cells outside segregation unitEarlier report
“There is no mandatory requirement for a HMP Prison to have access to a Safer Cell (one with reduced ligature points).”
The response stated
“We recognise that prisoners may feel vulnerable during their time in custody and HMPPS uses the Assessment, Care in Custody, Teamwork (ACCT) case management approach to support people at risk of self-harm and suicide. As part of any case review, those present will consider a range of measures to mitigate risk, including the prisoner's location and whether any possessions need to be removed or returned, and this may include moving the prisoner to a cell that is more appropriate to manage their risk”
Raised again
1 year 11 months later
“A further concern raised by the evidence relates to the lack of any attempt to cost structural cell improvements to mitigate, in at least some cells on each wing, the most obvious of ligature points in the Victorian Prison estates' cells, namely the readily accessible fixed bars at the windows.”
Both reports highlight failures to mitigate ligature points in prison cells to prevent self‑harm by hanging. The earlier report calls for mandatory safer cells with reduced ligature points, while the later report stresses the need to assess and fund structural fixes for obvious ligature points such as window bars.
Earlier report
“The sufficiency of information sharing and coordination between the police, hospital Trust and probation service.”
The response stated
“The information-sharing concordat has been reinforced. Additionally, the new Trust holds localised police liaison emergency care meetings and will ensure that the probation service is invited to improve information sharing in this regard.”
Raised again
8 years 3 months later
“Essex Police were aware that [the deceased] was under the care of the crisis mental health team and that the exacerbation of her mental health crisis was linked to a matter that was being investigated as a Hate Crime.”
Both reports highlight shortcomings in information sharing and coordination between Essex Police and mental health services.