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
“insufficient or inadequate instruction of both police and ambulance crew about the critical issues of recognising and responding to a medical emergency and the effects of restraint including positional asphyxia.”
The response stated
“A revised policy is due to be signed-off this year.”
Stated timescale: this year
Raised again
4 years 2 months later
“There was an evident lack of knowledge and/or concern on the part of the attending officers of the requirements of the Mental Capacity Act (MCA) 2005, particularly when it came to the decision to use force against and restrain [the deceased].”
Same coroner as the earlier report.
Both reports highlight shortcomings in training and awareness regarding the safe use of restraint and its medical consequences.
Royal College of Pathologists · National body
Inaccurate post mortem sampling in suspected anaphylaxis casesEarlier report
“- If bloods are taken at hospital that they are not destroyed in a suspected case but retained for testing”
The response stated
“The Royal College of Pathologists is currently updating its autopsy practice guidelines for suspected acute anaphylaxis. The updated guidelines will include contact details for the UKFAR and direct pathologists to report fatal anaphylaxis cases to the UKFAR.”
Raised again
3 years later
“a. blood samples for mast cell tryptase and sp IgE serology 2 suspected allergens b. stomach contents to be immediately stored (and/or frozen) by the pathologist for the analysis of the presence of the triggering allergen”
Both reports call for improved post‑mortem sampling in suspected anaphylaxis cases, especially retaining blood and stomach contents for allergen testing.
North Staffordshire Combined Healthcare NHS trust · NHS body
Lack of allocated care coordinator and psychiatric nurse appointmentsEarlier report
“The allocation of the Care Co-Ordinator was of concern as there was no system to ensure that a Care Co-Ordinator was actually being allocated into this role.”
The response stated
“The revised Trust Care Management Policy provides expectation in terms of the timeframes required for allocation, assessment, care planning and review (see appendix 1). Training for all Care Co-ordinators has taken place to ensure that staff are aware of the full requirements of their role. Assurance that this process is followed is monitored through the weekly review of compliance reports, overseen by Team Leaders. This data is further reviewed at Service Manager and Associate Director Level”
Stated timescale: October 31st 2021
Raised again
4 years 4 months later
“Evidence emerged during the inquest that Mrs [name redacted] was allocated a Community Psychiatric Nurse, and key worker in November 2024 but had not received any appointments to the date of her death on the 11 March 2025.”
Same coroner as the earlier report.
Both reports highlight that patients are allocated a mental health worker but the allocated worker does not actually provide the expected care or appointments. The underlying issue is the absence of a reliable system or policy to ensure the allocated role is fulfilled.
Southern Health NHS Foundation Trust · NHS body
Fragmented communication between mental and physical health servicesEarlier report
“there is and remains a fragmented relationship between mental health and physical health services, with little inter-service connectivity.”
The response stated
“The creation of this new provider is progressing at pace (Project Fusion) with the new legal entity due to be in place by 1 April 2024.”
Stated timescale: 1 April 2024
Raised again
2 years 4 months later
“If the presentation at the hospital was for a mental health related issue, then the OPMH team is likely notified as there will be contact with the psychiatric liaison service in the hospital.”
Both reports highlight a lack of communication and connectivity between mental health and physical health services, leading to missed information about patients' physical health crises.
Earlier report
“there was no clear system or expectation regarding the quality of checks on a resident who exhibited signs of being unwell.”
The response stated
“we will require the registered provider to provide an action plan with clear timescales for completion of each action identified and will review progress against this action plan in line with our processes.”
Stated timescale: 26 July 2024
Raised again
1 year 6 months later
“During the course of the inquest it was difficult to be clear at times as to what care had been delivered or what steps had been taken because the documentation relating to care and risk was poor.”
Same coroner as the earlier report.
Both reports highlight inadequate documentation systems that hinder proper monitoring of resident care and risk. The later report adds specifics about falls assessments and policy adherence while sharing the core issue of poor documentation.
Driver and Vehicle Licensing Agency · National body
Inadequate medical assessment of drivers' health conditionsEarlier report
“Consideration should be given to more frequent, rigorous testing and to consider the duties that should be placed on the driver, their medical practitioners and also family members/carers to report changes in presentation or health to the Driver and Vehicle Licensing Agency.”
The response stated
“we have contacted the Royal College of General Practitioners (RCGP) to alert them to these issues, so they can consider how best to raise awareness of this particular case and its implications with their members.”
Raised again
4 years 2 months later
“Drivers may not self-report medical conditions due to a variety of reasons. This can be due to due to a lack of understanding, insight, or simply because someone has not explicitly told them what to do or how to do it”
Both reports highlight the problem that drivers' medical conditions are not being reported to the DVLA, which can lead to unsafe driving. They share the concern that current mechanisms for reporting health changes are insufficient.
Driver and Vehicle Licensing Agency · National body
Inaccurate medical information provided to DVLA by driversEarlier report
“For whatever reason the deceased did not seek the medical report from his own GP, who would have known about his medical condition and who therefore would not have been able to support the application.”
The response stated
“The DVLA will continue to work closely with all relevant stakeholders to raise awareness of the impact medical conditions may have on fitness to drive and continue to explore any potential options for further improvements”
Raised again
10 months later
“I heard evidence in this inquest concerning the requirement of drivers' to self-notify the DVLA of any medical conditions that may interfere with their driving.”
Both reports highlight the problem that drivers may fail to disclose relevant medical conditions to the DVLA, relying on self‑reporting without adequate verification. The earlier report focuses on the use of independent GPs who cannot check the information, while the later report stresses the general requirement for self‑notification and its ineffective enforcement.
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
6 months later
“I heard evidence in this inquest concerning the requirement of drivers' to self-notify the DVLA of any medical conditions that may interfere with their driving.”
Both reports highlight reliance on drivers self‑notifying the DVLA of medical conditions that affect driving. They identify the same gap in the licensing system regarding self‑reporting.
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
7 months later
“I heard evidence in this inquest concerning the requirement of drivers' to self-notify the DVLA of any medical conditions that may interfere with their driving”
Both reports highlight the risk that drivers with medical conditions do not inform the DVLA, leaving those conditions unmonitored. The earlier report focuses on undiagnosed dementia and epilepsy, while the later report addresses the general self‑notification requirement and ambiguous medical advice.
HMP Berwyn · Prison or detention
Illicit drug accessibility in prisonEarlier report
“evidence at the inquest confirmed that the continuing availability and use of novel psychoactive substances.”
The response stated
“the Governor of Berwyn and the Regional Substance Misuse lead for HMPPS Wales have revised the prison's Drug Strategy. This primarily focuses on restricting the availability of illicit items, ensuring that there are appropriate consequences for those found in possession, and offering appropriate support for dependent users.”
Raised again
5 years 11 months later
“It was not surprising, therefore, that in our survey, 60% of prisoners said it was easy to get illicit drugs at Berwyn”
Both reports highlight the ongoing availability and use of psychoactive substances within HMP Berwyn as a risk to prisoner health. They describe the same hazard—illicit drug accessibility—despite differing data and timeframes.
Earlier report
“My concern here Is that handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital.”
The response stated
“have been strengthened, with the Division of Urgent Care now assuming full responsibility for the Corporate Site management team to ensure a full and co-ordinated focus is maintained on safe patient flow and ambulance handover delays. Other”
Raised again
1 year 11 months later
“However, at the same time, the longest handover time at Northampton General Hospital was 5 hours and at Kettering General Hospital it was 7 hours.”
Both reports identify excessive ambulance-to-hospital handover delays as a safety issue affecting emergency patient flow. They differ in the specific hospitals cited and the quantitative details of the delays.
Earlier report
“The target for hospital staff to take responsibility for the care of patients from ambulance crew is within 15 minutes of the ambulance arriving at an Emergency Department”
The response stated
“we published our 'Delivery plan for recovering urgent and emergency care services' which aims to deliver sustained improvements in waiting times. Our ambitions for this year are to improve A&E waiting times to 78% of patients to be admitted, transferred, or discharged from A&E within four hours by March 2025, and to reduce Category 2 ambulance response times to 30 minutes on average across this fiscal year.”
Stated timescale: March 2025
Raised again
1 year 11 months later
“I understand that nationally, the target time for handover from ambulance to hospital staff is 15 minutes. In the present case, the handover from ambulance to nursing staff at John Radcliffe Hospital took 25 minutes.”
Both reports highlight that the national target for ambulance-to-hospital patient handover is 15 minutes and that actual handover times far exceed this target, causing significant delays.