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
“During a Mental Health triage with the the Mental Health and Social Inclusion Hub on 8th February 2023 there was a failure to complete the Risk Assessment in relation to his risk of suicide.”
The response stated
“An exploration of risk would entail a conversation around factors such as risk to self, risk to others or self- neglect. If during that conversation any risks are identified these would be explored in further detail to include intent, severity, access to resources and following this a robust safety plan formulated collaboratively between professional, the service user and carer (if”
Stated timescale: December 2023
Raised again
1 year 1 month later
“Both assessments, were incorrect, and took account of incorrect information because neither team had access to the others computer system.”
Both reports highlight problems with suicide risk assessments – the earlier report cites failures to complete assessments, while the later report notes assessments were done incorrectly due to lack of shared information and insufficient staff training.
Department for Transport · National body
Young drivers carrying peer passengers increase collision riskEarlier report
“The carrying of passengers in the car increases the likelihood of death or injury not only to the driver but also to the passengers being carried, therefore multiplies the risk.”
The response stated
“the Department has decided to use the introduction of GDL in Northern Ireland as a pilot, to gather evidence on the potential for GDL in Great Britain.”
Raised again
6 years 6 months later
“There is currently ongoing public concern that inexperienced drivers are able to carry young passengers within the first six months of having passed their test.”
Both reports highlight that carrying passengers increases the risk for inexperienced drivers. The later report specifies the risk applies within the first six months after passing the test.
Department for Science · National body
Online suicide method guides and forumsEarlier report
“The downloaded document provides step by step instruction on how to end your life with specific advice and direction on the use of certain equipment.”
The response stated
“The government is committed to delivering a renewed drive to tackle the number of lives lost to suicide. Cross-government action is key in achieving this, and coordinated action is taking place across government to enable us to rapidly identify and proactively tackle emerging methods of suicide as quickly and effectively as possible, with a series of interventions to reduce access and awareness of dangerous methods.”
Stated timescale: as quickly and effectively as possible
Raised again
1 year 1 month later
“[the deceased] accessed an online 'suicide forum' where she was able to access information on how to take her own life and where she obtained advice/information on misleading professionals and her family as to her thoughts and intentions.”
Both reports highlight the danger of individuals obtaining suicide‑method information through online sources.
Ofcom · National body
Online suicide forums and self-harm facilitation sitesEarlier report
“The concern here is that this site & potentially similar self-harm & suicide”
The response stated
“we are committed to driving industry improvements by engaging with the largest and riskiest services via continuous 'regulatory supervision.'”
Raised again
1 year 5 months later
“[the deceased] accessed an online 'suicide forum' where she was able to access information on how to take her own life”
Both reports highlight the danger of vulnerable individuals accessing online platforms that provide information or methods for self‑harm and suicide. The earlier report focuses on a specific self‑harm/suicide facilitating site, while the later report cites a suicide forum and a social media platform used to obtain method details.
Ofcom · National body
Online suicide forums and self-harm facilitation sitesEarlier report
“(3) [REDACTED], is a forum that permits material to be exchanged and viewed within its open chatrooms whereby suicide is encouraged, assisted, counselled and procured through the provision and exchange of information and methods.”
The response stated
“The act's illegal safety duties will apply to all in-scope 'user-to-user' services which allow users to post content online, or to interact with each other - including online forums. This means that once these duties are in force, they will be required to have systems and processes in place to proactively prevent users from encountering priority illegal content via their service and to minimise the length of time for which such content is present.”
Stated timescale: once these duties are in force
Raised again
1 year 3 months later
“[the deceased] accessed an online 'suicide forum' where she was able to access information on how to take her own life”
Both reports highlight suicide forums that enable users to obtain information and methods for self‑harm.
Cwm Taf Morgannwg University Health Board · NHS body
Discharge without surgical review or sepsis recognitionEarlier report
“(3) Premature discharge post-operatively from the recovery unit with the missed opportunity to recognise the adverse effect of sepsis when they occurred.”
The response stated
“Review and provide definite warnings (oral and written) of sepsis when consenting patients to TRUS, and upon their discharge.”
Stated timescale: 11 March 2020
Raised again
5 years later
“[the deceased] should have been referred for surgical review rather than being discharged.”
Both reports highlight that patients were discharged from hospital without adequate clinical review, leading to preventable harm. The earlier case involved missed sepsis signs after TRUS surgery, while the later case concerned lack of surgical review before discharge.
Birmingham City Council · Local authority
Incorrect section placement and missing information during assessmentsEarlier report
“When Mr [name redacted] was admitted to hospital on 15/03/19 he was placed on S2 of the Mental Health Act when his clinical team had specifically recommended he be placed on S3.”
The response stated
“We will continue to engage with other agencies to enable the Trust to learn from incidents and improve patient care.”
Raised again
5 years 6 months later
“Mental Health assessments: The inquest heard evidence that there were barriers to the use of S2 and S3 of the Mental health Act due to AMPH resistance, administrative challenges and resourcing.”
Same coroner as the earlier report.
Both reports highlight problems with the application of Sections 2 and 3 of the Mental Health Act due to decisions or resistance by Approved Mental Health Practitioners. The earlier report cites a specific incorrect section placement, while the later report describes broader barriers to using those sections.
Earlier report
“The evidence before me showed that police officers were trained to deal | with suspects who had swallowed drugs. The evidence however | disclosed a complete lack of knowledge of the risks of choking when suspects were either arrested or in the process of being detained”
The response stated
“Since August 2016, all officers are now issued with a personal Pocket Face Mask and instructed on its correct use in mouth to mouth resuscitation.”
Stated timescale: August 2016
Raised again
6 years 4 months later
“The court heard that College of Policing Guidance for Custody Officers and Detention Officers provides that "...If officers know or suspect that a detainee has swallowed or packed drugs...they must treat the person as being in need of urgent medical attention and transfer then straight to hospital"”
Both reports concern the risk to individuals who have swallowed or packed drugs and the need for appropriate police response and medical attention. They differ in focus: the earlier highlights insufficient training on choking risks during arrest/detention, while the later points out missing guidance for non‑arrest detainees undergoing drug searches.
Earlier report
“Yorkshire Ambulance Service were on their highest level of escalation at that time with significant delays at hospital handover caused or contributed to the delay in an ambulance being available to [the deceased].”
The response stated
“Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25.”
Stated timescale: 2024/25
Raised again
1 year 7 months later
“Delay in ambulance response attributable to delays in handover of patients at Royal Cornwall Hospital”
Both reports identify delays in patient handover at hospitals as a cause of prolonged ambulance response times. The specific hazard is the same, though the ambulance trusts and hospital locations differ.
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
8 months later
“Delay in ambulance response attributable to delays in handover of patients at Royal Cornwall Hospital”
Both reports identify ambulance response delays caused by prolonged patient handover times at hospital emergency departments. The core concern is that these handover bottlenecks create a risk of avoidable deaths.
Earlier report
“availability of 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
10 months later
“Delay in ambulance response attributable to delays in handover of patients at Royal Cornwall Hospital”
Both reports identify hospital handover delays as the cause of delayed ambulance responses, creating a risk to life.
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 3 months later
“Delay in ambulance response attributable to delays in handover of patients at Royal Cornwall Hospital”
Both reports identify ambulance handover delays as a factor that prolongs emergency response times and endangers patients. The earlier report concerns Welsh ambulance service handover delays, while the later report focuses on delays at Royal Cornwall Hospital in Cornwall.