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
Earlier report
“handover delays are impacting upon response times in respect of patients requiring emergency treatment”
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 9 months later
“delays in ambulances clearing ED was still having a very significant impact on their ability to respond to calls”
Both reports identify ambulance handover delays as reducing the service's ability to respond to emergency calls. They describe the same mechanism—excessive handover times leading to longer response intervals.
Earlier report
“Although EMAS reported a slight improvement in the issue of resourcing following the adoption of the newer NHS Pathways triage process the delay in paramedics attending Category 2 calls has not been resolved to within target ranges.”
The response stated
“the Health Secretary has ordered a full and independent investigation into NHS performance to provide a frank assessment of the issues and challenges it faces”
Raised again
1 year 2 months later
“However delays in ambulances clearing ED was still having a very significant impact on their ability to respond to calls including category 2 calls such as the one for Mr [name redacted].”
Both reports identify delays in ambulances clearing hospital emergency departments as a factor that impairs timely response to emergency calls.
Home Office · National body
Ketamine misclassification as Class B drugEarlier report
“Maintaining its classification as a Class B drug was likely to encourage others to start to use it or continue to use it under the false impression it is”
The response stated
“I intend to commission the ACMD to conduct an updated harms assessment of ketamine as part of the forthcoming three-year work programme commission cycle.”
Raised again
9 months later
“Ketamine's classification as a class B controlled drug may give an impression that the dangers associated with its use are reduced as compared with class A drugs.”
Both reports highlight that classifying ketamine as a Class B drug creates a false impression that it is less harmful than Class A drugs, encouraging use despite serious health risks.
Essex Partnership NHS Foundation Trust · NHS body
Delay in prescribing and administering therapeutic medication for first episodeEarlier report
“[REDACTED] Lorazepam was prescribed and administered on 25 May 2022 at hospital and evidence was that this was sub-therapeutic.”
The response stated
“The Trust is currently considering the need to expand the number and types of medications available for nurses to use via PGD. In order to inform these considerations, the Trust's Director of Pharmacy and Service Managers for urgent care pathways are collaboratively reviewing the medication needs for the services.”
Stated timescale: end of July 2023
Raised again
2 years 3 months later
“(2) There was confusion about the mental health Trust prescribing dose for Ms [name redacted] antidepressant medication and an overreliance on discussions with her rather than checking the prescription dose and communication with the GP was delayed.”
Same coroner as the earlier report.
Both reports highlight problems with the Trust's medication management for mental health patients, specifically delays or failures in ensuring appropriate prescribing and administration.
South West London Integrated Care Board · Commissioner
Insufficient mental health beds leading to ED psychiatric patient detentionEarlier report
“The Matron in Acute and Urgent Care confirmed bed capacity remains an ongoing problem and has not been resolved.”
The response stated
“The Trust (SWLStG) fully acknowledges the concern regarding insufficient bed capacity in London and the reason why the Coroner has cause to raise these concerns.”
Raised again
1 year 2 months later
“patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds.”
Both reports highlight insufficient psychiatric/mental health bed capacity leading to patients being held in emergency departments while awaiting admission. The earlier report focuses on London-wide bed shortages, while the later report concerns Surrey-specific delays in the ED of Epsom General Hospital.
Earlier report
“privacy, toilet facilities and confidentiality. I understood from the evidence of the clinicians that they were concerned that patients were being moved into the Corridor but there appeared to be no other option when the Emergency Department exceeds capacity.”
The response stated
“The report raises concerns over emergency department capacity, poor patient flow and the use of corridor care at Royal Sussex County Hospital (RSCH) and nationally. I understand that your report and matters of concerns have also been sent to NHS England, and they are best placed to respond with the specific actions being taken locally to improve urgent and emergency care performance at RSCH.”
Raised again
10 months later
“During the inquest I heard evidence from clinicians at University Hospitals Sussex NHS Foundation Trust that when the Emergency Department of the Royal Sussex County Hospital, Brighton reached capacity patients would be moved to and treated in the corridor as there was no clinical area available to do so.”
Same coroner as the earlier report.
Both reports describe the use of hospital corridors to care for patients when emergency departments exceed capacity and there is no alternative clinical space. They highlight the same nationwide practice driven by ED overcrowding.
Earlier report
“As a result of the lack of appropriate space Mr [name redacted] an elderly and vulnerable patient was treated in the corridor for periods during his stay in the ED.”
The response stated
“The new approach will incorporate two elements: - Implementation of the new national NHS 111 First Initiative, which will ask patients to call 111 prior to attending an Emergency Department - A new pre-Emergency Department triage and streaming system Both of these will help ensure patients are streamed or referred to the most appropriate service for their needs. This will include a wide range of community and acute-based services and will ensure only patients who need an Emergency Department go”
Stated timescale: April 2022
Raised again
5 years later
“when the Emergency Department of the Royal Sussex County Hospital, Brighton reached capacity patients would be moved to and treated in the corridor as there was no clinical area available to do so.”
Both reports describe patients being treated in emergency department corridors due to insufficient clinical space when the department is at capacity. The core concern is the lack of appropriate space leading to corridor care.
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 4 months later
“Officers who were present during Mr [name redacted] cardio-respiratory arrest had different training with regard to first aid and basic life support.”
Both reports highlight insufficient first aid and CPR training among prison officers who have direct contact with prisoners. They describe the same hazard of inadequate life‑support training leading to uncertainty during medical emergencies.
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
9 months later
“Officers who were present during Mr [name redacted] cardio-respiratory arrest had different training with regard to first aid and basic life support. During the course of the inquest, evidence was heard that whilst all uniformed prison officers would have regular training in respect of control and restraint, not all had recent (if any) training in first aid or basic life support.”
Both reports highlight that prison officers lack adequate first aid and CPR training, which compromises emergency response.
Earlier report
“(2) Prison staff did not receive a briefing about prisoners with medication in possession in accordance with PS24/2011”
The response stated
“Following evidence heard at the inquest, you have raised concerns about the appropriate monitoring of prisoners suspected to be under the influence of illicit substances during the night state and that prison staff were not sufficiently briefed about prisoners keeping medication in their possession. You have also raised a concern in relation to healthcare staff sharing relevant medical information with prison staff. I note that you have also addressed your report to Oxleas NHS Foundation Trust”
Stated timescale: end of the year
Raised again
1 year later
“(2) Prisoners can have access to certain medication to hold in their possession which could be accessed by other prisoners and there is a lack of national policy, and local policy at HMP Guys Marsh, from a healthcare and prison perspective, around the governance of medication held in possession in the prison estate.”
Both reports highlight problems with how medication kept in prisoners' possession is managed, noting insufficient guidance or policy. The earlier report stresses lack of staff briefing, while the later report points to missing national and local policies governing possession and access.
His Majesty's Prison and Probation Service · National body
Inadequate ACCT training leading to incomplete documentationEarlier report
“Training regarding the ACCT process. In previous prison deaths and in response to previous PPO reports, promises have been made about training”
The response stated
“The following information describes the commissioning arrangements for healthcare for someone being held in police custody.”
Raised again
8 years 5 months later
“The prison officers who gave evidence in relation to observations on 28th and 29th June 2024 were relatively new recruits, one having 3 months experience following POELT training and the other 1 month experience.”
Both reports highlight inadequate training or understanding of the ACCT process among prison staff. They describe a gap between training provided and actual competence in applying the process.
National Highways · National body
Standing water on road leading to hydroplaningEarlier report
“The scene of the collision is in a natural 'bowl' and that, unless effectively drained, it is a point at which standing water will accumulate during and/or after heavy rainfall;”
The response stated
“The drainage scheme is progressing as planned through the design and development phases with an estimated start date on the A46 in February 2018. The work will take place over a period of approximately 20 weeks with a planned completion date of June 2018.”
Stated timescale: June 2018
Raised again
7 years 10 months later
“(2) Whilst the precise cause of the flooding is unknown, a more regular maintenance schedule may have prevented the buildup of vegetation within the gullies and therefore assisted in the drainage of the heavy rainfall experienced that day”
Both reports highlight inadequate drainage leading to standing water on the road. The earlier report cites a blocked drain in a natural bowl, while the later report notes flood risk and vegetation‑blocked gullies reducing drainage.