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 &/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 8 months later
“the main reason for the delay in dispatching emergency ambulances remains the length of time it is taking for ambulances to be released from the emergency department”
Both reports identify ambulance handover delays at the emergency department as the cause of prolonged ambulance response times. They describe the same mechanism—delays in releasing ambulances from the ED leading to risks for patients needing emergency care.
His Majesty's Prison and Probation Service · National body
Inadequate ACCT training leading to incomplete documentationEarlier report
“In evidence it was clear that the ACCT document was the only written document used for sharing information between the healthcare staff employed by the NHS trust and the prison security staff.”
The response stated
“The Safety Intervention Meeting (SIM) is a multi-disciplinary safety risk management meeting, chaired by the Senior Management Team (SMT), providing support and multi-disciplinary guidance to Case Coordinators and case review teams.”
Raised again
2 years 2 months later
“(b) inconsistent understanding of healthcare access to the NOMIS by both prison and healthcare staff;”
Both reports highlight problems with communication and information sharing between prison and healthcare staff concerning access to the NOMIS system.
Greater Manchester Integrated Care · Other
Delayed discharge due to insufficient social care placementsEarlier report
“He had to remain there due to a lack of suitable care/nursing beds. This meant that he was in an unsuitable care setting and that a bed that could have been utilised for an acute patient was not available;”
The response stated
“1. Home Finders Team (as described above) that are focussed specifically on supporting timely and appropriate placements for patients ready for discharge.”
Raised again
1 year 9 months later
“The inquest heard evidence that [the deceased] was only in hospital at the point of her fall because her discharge had been delayed due to a shortage of a suitable social care placement.”
Same coroner as the earlier report.
Both reports highlight that a shortage of suitable social care or nursing home beds delays patient discharge, keeping individuals in acute hospital settings unnecessarily. This results in unsuitable care environments and reduced bed availability for other patients.
Greater Manchester Integrated Care · Other
Delayed discharge due to insufficient social care placementsEarlier report
“Mr [name redacted] was assessed as being suitable for discharge on 18th December. He remained in an acute hospital setting for a further 4 weeks due to challenges in identifying a suitable care home.”
The response stated
“the Greater Manchester NHS Foundation Trust agrees that, although it can take time to complete all the necessary arrangements for a safe and appropriate transfer of care for someone with complex needs, the time from a decision that Mr [name redacted] was medically optimised (18 December 2023) to his actual transfer to Hilltop Hall Nursing Home (11 January 2024) was too long.”
Stated timescale: 18 December 2023 to 11 January 2024
Raised again
9 months later
“The inquest heard evidence that [the deceased] was only in hospital at the point of her fall because her discharge had been delayed due to a shortage of a suitable social care placement.”
Same coroner as the earlier report.
Both reports highlight a shortage of suitable social care placements causing patients to remain in acute hospitals longer than clinically needed. This leads to delayed discharges and impacts bed availability for other patients.
Greater Manchester Integrated Care · Other
Delayed discharge due to insufficient social care placementsEarlier report
“The evidence was that speedier discharges would occur if there was improved availability of social care and that this would improve outcomes for elderly patients and reduce the risk of preventable deaths occurring.”
Raised again
2 years later
“Delayed discharges such as [the deceased]'s reduces the availability of beds for other patients and creates a knock-on impact across the hospital particularly in relation to the Emergency Department.”
Same coroner as the earlier report.
Both reports identify delayed patient discharge caused by insufficient social care placements as a safety issue. The later report adds that these delays also affect bed availability and increase pressure on the Emergency Department.
Home Office · National body
Unrestricted domestic purchase of substanceEarlier report
“[REDACTED] can be purchased domestically with no restrictions save a duty on sellers to report suspicious transactions;”
The response stated
“The group has worked with businesses, including online suppliers and manufacturers of the substance, to reduce people's ability to purchase it for non-legitimate purposes including suicide, and to raise awareness around safeguarding concerns with businesses where required.”
Raised again
8 months later
“[REDACTED] can be purchased domestically with no restrictions save a duty on sellers to report suspicious transactions;”
Same coroner as the earlier report.
Both reports highlight that the substance can be bought domestically without restriction except for a seller duty to report suspicious transactions. They also note the lack of controls on purity/quantity and import from abroad.
Earlier report
“(10) The ability for UK users to purchase [REDACTED], through Amazon in the United States and to take delivery in the United Kingdom without effective border and/or custom controls.”
The response stated
“seeking to tackle at source the suppliers of harmful substances for the purposes of suicide”
Raised again
1 year 7 months later
“[REDACTED] can be purchased from abroad and imported to Great Britain with no restrictions;”
Both reports highlight that a harmful substance can be bought from overseas and brought into the UK without effective border or customs controls. The core concern is the lack of restrictions enabling unchecked importation.
Ministry of Justice · National body
Delayed ambulance call for medical distressEarlier report
“The Prison did not have a set policy about when an ambulance should be called.”
The response stated
“Since Mr [name redacted] death Prison Service Instruction 2013/03 Emergency Response Codes has been issued. The PSI reminds staff who can call a medical emergency, and provides guidance on the use of the correct medical emergency codes, and what information should be communicated to the control room from the scene of the incident. It also states that all Governors must have a Medical Emergency Response Code protocol in place that is based on the PSI and that all prison staff must be made aware of and”
Stated timescale: 2013/03
Raised again
10 years 7 months later
“It is essential that an ambulance is called in all cases where there are serious concerns about the health of a prisoner and that access to both the prison and the individual prisoner is not delayed;”
Both reports highlight problems with the prison’s process for deciding when to summon an ambulance for a prisoner in medical distress. The earlier report notes the absence of a clear policy, while the later report stresses that an ambulance must be called without delay in all serious cases.
Earlier report
“There was an inordinate and inexcusable delay in gaining entry to the premises where it was known that the caller to the ambulance service had apparently collapsed mid-call.”
The response stated
“The Specialist Operational Training Unit which is responsible for training officers in both decision making and tactics will use this example during their method of entry training modules.”
Raised again
10 years later
“The full background of the deceased, her history of falls, her recent bereavement and high risk to have suffered an adverse medical episode, or deliberate or unintended physical harm raised the expectation on the part of the family, that having called the emergency services, entry would be forced to the deceased's residence as they were of the view that there was a real and immediate risk of death or serious harm having occurred.”
Both reports highlight a delay in gaining entry to a residence because responders underestimated the urgency of the situation.
Cumbria Health Limited · Company or provider
Delayed urgent referrals and escalationsEarlier report
“Given the above I am concerned that future deaths may occur if urgent requests are not dealt with more promptly”
The response stated
“We will put on educational sessions to update our clinicians on the mental capacity act, managing challenging scenarios with particular emphasis on how this is documented in a patient record”
Raised again
1 year later
“[the deceased]'s case was sent electronically to the service, marked for 2 hour attention”
Same coroner as the earlier report.
Both reports highlight that urgent requests or referrals are not being handled promptly, leading to avoidable harm. The earlier report focuses on delayed handover and after‑hours coverage, while the later report concerns an electronically flagged 2‑hour referral that was not acted on due to workload.
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 and shortly afterwards suffered a catastrophic cardiovascular compromise.”
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
10 months later
“The lack of serial nursing observations was a fundamental omission from [the deceased]'s care.”
Same coroner as the earlier report.
Both reports highlight that failing to obtain or record nursing observations in pediatric emergency care can lead to serious harm. They share the concern that absent observations should be treated as abnormal and escalated promptly.
NHS England · National body
Inconsistent access to thrombectomy servicesEarlier report
“Evidence was heard that there is no provision in Lancashire for Thrombectomy Service following a stroke after 5pm and that neighbouring Trusts who provide this service are no longer able to accept patients from Lancashire.”
The response stated
“The interim offer for Lancashire is in the process of being formalised, led by the Medical Director for Specialised Commissioning who is working with the three units across the North West.”
Raised again
1 year 7 months later
“The evidence revealed that there is a gap in the availability of the time critical and potentially lifesaving thrombectomy emergency procedure to patients that have suffered a severe stroke in the South West.”
Both reports highlight a lack of thrombectomy service for stroke patients in a specific region.