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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Barts Health NHS Trust · NHS body
Over-reliance on NEWS algorithm and inadequate monitoring of deteriorating EDEarlier report
“Factors in the Emergency Department including, patient congestion, over-reliance on the NEWS algorithm and a lack of compassion and clinical curiosity contributed the outcome.”
The response stated
“the trust will be responding to you directly on the steps they are taking locally; this includes action to help improve the awareness and care provided in the emergency department for patients with sickle cell anaemia”
Raised again
10 months later
“There is no electronic observation system in place within the A&E department of Whipps Cross Hospital (such as Live Note). Patients presenting with high NEWS scores are not therefore automatically brought to the attention of clinical supervisors.”
Both reports highlight failures in the emergency department related to the use of NEWS scores and inadequate monitoring of deteriorating patients.
Earlier report
“They were told that the reason for the delay was confusion between Surrey Police and the Metropolitan Police.”
The response stated
“I will ensure that appropriate actions are identified and completed to ensure that any communications of this nature are promptly escalated in the future.”
Raised again
11 months later
“It is hard to understand the decision (made by more than one police caller) not to leave any voicemail/message.”
Both reports highlight shortcomings in police communication procedures that could lead to avoidable harm. The earlier report cites inter‑force confusion delaying a welfare check, while the later report notes absent guidance on leaving voicemails during urgent inquiries.
Essex Partnership University NHS Foundation Trust · NHS body
Absence of mental health liaison during 72‑hour hold and missing discharge noteEarlier report
“During the waiting period of up to 72 hours, Mental Health Liaison will not attend the acute ward or make assessment of the presenting risks of self-harm”
The response stated
“In order to strengthen collaborative working across the two Trusts, a project group for development of the 'joint protocol' is being put into place. The first meeting with attendees from both Trusts has been arranged for 23rd September 2024”
Stated timescale: 23rd September 2024
Raised again
1 year later
“There was no record of the mental health liaison nurse review on 24 June 2023 and the discharge of Mr [name redacted] from EPUT.”
Same coroner as the earlier report.
Both concerns involve the absence or inadequacy of mental health liaison involvement/records for patients needing assessment. The earlier report notes a gap in liaison attendance during up to 72‑hour waits, while the later report highlights a missing record of a liaison nurse review on a specific date.
Essex Partnership University NHS Foundation Trust · NHS body
Incomplete investigation of patient observationsEarlier report
“The Trust investigation was materially incomplete and there was a lost an opportunity to:”
The response stated
“The Trust has now convened a PSIRF Improvement Oversight Project Board which is chaired by the Executive Nurse and will report into the Safety of Care Committee which is chaired by the Chief Executive Officer.”
Raised again
1 year 6 months later
“The information used to inform a potential investigation requirement contained significant omissions and was not consistent with the information known to the Trust.”
Same coroner as the earlier report.
Both reports highlight that the Trust's investigative processes suffered from missing or inaccurate information, leading to incomplete assessments. The earlier report cites omitted details in a death investigation, while the later report notes incorrect data in a decision‑monitoring tool.
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 6 months later
“NHS England national service specifications provide for a 24/7 thrombectomy service which is not currently being delivered in Lancashire and there is no clear plan to deliver that service”
Same coroner as the earlier report.
Both reports highlight the absence of a reliable out‑of‑hours thrombectomy service for stroke patients in Lancashire. They note that while national or regional specifications call for 24/7 availability, no effective coordination or plan exists to deliver the treatment after regular hours.
Earlier report
“The raised section of the tarmac separating the slip road from the main carriageway on the A1(M) approaching Junction 6 northbound is potentially hazardous.”
The response stated
“The raised section of kerb separating the off slip road from the main carriageway on the A1(M) at Junction 6 northbound is addressed at point 6a. below.”
Stated timescale: March 2020
Raised again
8 years 8 months later
“The continued presence of this hazard (the mound of earth on a tarmac construction) places road users at risk of death”
Both reports describe a raised obstruction on the road surface that can cause loss of vehicle control. The earlier report cites a raised tarmac/kerb section, while the later report cites a mound of earth on tarmac, presenting the same type of hazard.
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 6 months later
“Response times for ambulances attending acute medical incidents continue to be impacted by severe delays in patient handovers at acute hospitals preventing ambulances and their crews returning to service.”
Both reports describe how prolonged patient handover delays at hospitals extend ambulance response times and keep crews unavailable.
Earlier report
“ambulance crews is continuing to be compromised by delays at hospitals resulting in delays in response times which creates a risk to the life”
The response stated
“The plan outlined key actions to recover and improve urgent and emergency care services, including: - improving ambulance response times; - increasing ambulance capacity through growing the workforce (for example, increasing clinical capacity in control rooms); - alongside broader system actions to improve flow through hospitals and reducing handover delays; - speeding up discharges from hospitals; - expanding new services in the community.”
Stated timescale: 2023/24
Raised again
1 year 1 month later
“Response times for ambulances attending acute medical incidents continue to be impacted by severe delays in patient handovers at acute hospitals preventing ambulances and their crews returning to service”
Both reports describe ambulance response times being delayed because patients experience long handover waits at acute hospitals, which keeps ambulances and crews off the road. The core issue is hospital handover delays affecting ambulance availability.
Earlier report
“During the inquest evidence was given that ambulance availability is being jeopardised by crews being delayed at hospital when handing patients over to Accident and Emergency staff.”
The response stated
“We will be meeting with NEAS in September 2015 to discuss and monitor how they are managing their delivery of the service, what is their current position of staffing levels and identified vacant posts and their current recruitment position.”
Stated timescale: September 2015
Raised again
10 years later
“Response times for ambulances attending acute medical incidents continue to be impacted by severe delays in patient handovers at acute hospitals preventing ambulances and their crews returning to service.”
Both reports identify delays in patient handovers at hospitals as reducing ambulance availability.
Earlier report
“I am concerned that these continuing delays for ambulances at hospital handovers reflects a risk of deaths into the future.”
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
11 months later
“Response times for ambulances attending acute medical incidents continue to be impacted by severe delays in patient handovers at acute hospitals preventing ambulances and their crews returning to service.”
Both reports identify prolonged ambulance handover delays at hospital emergency departments as a safety issue. These delays impede ambulance availability and increase risks to patients needing timely care.
Earlier report
“The delay in an ambulance being despatched to the home address of the deceased who was clearly experiencing seizures/fits. The evidence showed that the main reason for the delay was the significant hand over delays”
The response stated
“We recognise lengthy handover delays are clearly unacceptable as they can impact not only on the ambulance service's ability to respond to subsequent calls in the community, but also on patient's experience. Handover delays are often symptomatic of pressures elsewhere within the unscheduled care system and should not be viewed in isolation which is why work is being undertaken nationally and locally to support improvements across the patient pathway through reducing inappropriate admissions to hospital”
Raised again
8 years 3 months later
“It took a total period of 15 hours and 13 minutes for an ambulance to attend upon [the deceased], by which time she was in cardiac arrest and resuscitation efforts were unsuccessful.”
Both reports identify hospital handover delays as the cause of prolonged ambulance response times. The core concern is that excessive handover times keep ambulances unavailable, endangering patients.
Earlier report
“During the course of the inquest the reason given for the significant delay to respond to the call was ambulances waiting at Emergency Departments to hand over patients”
The response stated
“Welsh Government has set a priority for improvement in patient flow and the reduction of delayed discharges (pathways of care delays). To build on this, the Welsh Government has also set health boards in-year aspirations in 2024/2025 to reduce ambulance patient handovers over 1 hour by 30% by December 2024”
Stated timescale: December 2024
Raised again
7 months later
“It appears to remain the case that the lack of social care provision and/or Community Hospitals means that those fit to be discharged from district general hospitals are not discharged”
Both reports highlight ambulance handover delays caused by hospital capacity issues. The earlier report focuses on ED overcrowding, while the later points to insufficient social care and community hospital beds leading to the same delay.