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
“The ambulance delay in [the deceased]'s case, on 10 to 11 July 2022, was due to the demand on the service and delays in the patient handover process at the two main hospitals servicing Cornwall:”
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 3 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 the main Cornwall hospitals.
Earlier report
“There remains limited understanding and awareness of the role of a Physician Associate both amongst medical colleagues, patients and their families.”
The response stated
“We are clear that statutory regulation is necessary for PAs and anaesthesia associates (AAs) and the UK and Scottish parliaments approved legislation in early 2024 which provides a legal duty for the GMC to regulate PAs and AAs from December 2024.”
Stated timescale: December 2024
Raised again
7 months later
“Lack of public understanding of the role of Physician Associate”
Both reports highlight insufficient awareness and understanding of the Physician Associate role leading to confusion about qualifications.
Department of Health and Social Care · National body
Lack of awareness of fatal side effects of clozapineEarlier report
“However it appears that many staff are not aware of the significance of this medication particularly when considering potential side-effects and warning signs of deterioration.”
The response stated
“My officials have made enquiries with a number of bodies on the matter of concern in your report that there should be routine therapeutic blood monitoring (testing of blood plasma levels) in patients who are prescribed clozapine.”
Raised again
6 years 3 months later
“The lack of awareness by a series of clinical staff of the potential fatal side effects of Clozapine”
Both reports highlight that clinical staff lack awareness of Clozapine's significant side‑effects and warning signs. The later report specifies fatal side‑effects while the earlier mentions significance and deterioration signs.
Department of Health and Social Care · National body
Insufficient inpatient bed capacity leading to delayed discharges and patient harmEarlier report
“The prolonged wait Mr [name redacted] had was a result of lack of bed capacity.”
The response stated
“Adoption of a single GM Discharge to Assess Referral Form - Triage of discharge to assess referrals within 30mins - Adherence to the guidance for COVID 19 testing for discharge and PPE requirements - The supply of 2 weeks medication supplies at the point of discharge from an acute hospital - Operation of a next day follow up process following discharge (localities to determine how this is delivered)”
Stated timescale: late April (formally approved)
Raised again
4 years 7 months later
“As an example the court was told that on the morning the inquest was heard there were patients who had been waiting 40 hours for a bed on a ward.”
Same coroner as the earlier report.
Both reports identify prolonged emergency department waits caused by insufficient bed capacity due to delayed discharges as a hazard leading to patient harm.
Essex Partnership University NHS Foundation Trust · NHS body
Inability to access GP medication records across systemsEarlier report
“I am concerned about the fact, if that is indeed right, that some clinicians in the psychology service may not be able to access notes made by clinicians in either other hospitals or other parts of the county.”
The response stated
“The Psychological Services Care Unit have been advised of this concern and have provided the following assurance. Every patient who is receiving psychological intervention on an inpatient unit and is in need of continued psychological intervention post discharge, will have a handover of care from the inpatient psychologist (verbal/in writing) to the Community Team psychological practitioner.”
Stated timescale: 2023
Raised again
1 year 2 months later
“Evidence was heard that the mental health crisis staff do not appear to have appropriate access to the primary care mental health System One records and there is a risk that vital information is not being shared.”
Both reports highlight that staff cannot access necessary mental health records across different service settings, risking gaps in information sharing.
Earlier report
“there is a 2.5 mile gap in the emergency refuge areas at this point; b) this section of the M6 is elevated and as such there is no land along the edge of the motorway to which occupants”
The response stated
“The coroner concluded that there was no evidence of a fault with the vehicle, iliness of the driver, or a hazard in the road which caused the driver to stop in a clearly marked live running lane on a high-speed road. The reason the driver stopped on the M6 motorway was not established "as part of the coronial process.”
Raised again
5 years 4 months later
“It was accepted that there was no area for vehicles to stop should they need to, unless they were near to the refuse areas spaced 1.6 miles apart, and the all lanes open motorways were not monitored.”
Both reports highlight the danger of vehicles stopping in a live lane due to insufficient emergency refuge areas along the motorway. They differ in the specific scheme (dynamic hard shoulder vs all‑lanes open) and the exact spacing of refuge areas.
Earlier report
“- The obvious and foreseeable risk posed by the absence of a hard shoulder on”
The response stated
“Highways England will publish this report shortly”
Stated timescale: shortly
Raised again
4 years 1 month later
“i) It was accepted at inquest that Mr [name redacted] was on an all lanes open motorway. This type of motorway has all lanes open for vehicles to use, and areas for vehicles to stop every 1.6 miles, but not areas in between.”
Both reports highlight the lack of adequate stopping places for vehicles on motorways without a hard shoulder or continuous refuge areas.
Earlier report
“I remain very concerned about resource issues for this ambulance service.”
The response stated
“The need for an urgent review of resources to reduce the risk of future deaths”
Stated timescale: 2016/17 contract
Raised again
8 years 9 months later
“There is insufficient Ambulance Service availability/resource to enable Ambulances to attend to patients in a timely manner and in accordance with relevant target attendance times.”
Both reports highlight insufficient ambulance resources leading to delayed response and patient handovers.
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
“There are excessive delays in Ambulance crews being released following attendance at hospital, due to delays in patients being handed over to hospital staff.”
Both reports describe ambulance crew availability being reduced because patients experience long handover delays at hospitals, leading to slower response times.
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
9 years 9 months later
“There are excessive delays in Ambulance crews being released following attendance at hospital, due to delays in patients being handed over to hospital staff.”
Both reports highlight that ambulance crews experience excessive delays when trying to hand over patients to hospital staff, which reduces ambulance availability.
Royal College of Paediatrics and Child Health · National body
Insufficient complex neonatal resuscitation trainingEarlier report
“It is a matter of concern that Consultant general paediatricians of the future will have a lower level of experience than is currently the case of complex neonatal resuscitation”
The response stated
“introduced a formal supervisor assessment that the trainee is ready to be on the tier 2 rota with remote supervision (i.e., a consultant on call from home). To agree that a trainee is ready for this step there needs to be agreement that there is evidence of: - Neonatal capabilities. - General paediatric capabilities. - Neonatal Life Support & Advanced Paediatric Life Support course, or equivalent. - Mandatory procedures (including airway maintenance”
Raised again
1 year 3 months later
“Consultant general paediatricians of the future will have a lower level of experience than is currently the case of complex neonatal resuscitation”
Both reports express concern that future consultant general paediatricians will have less experience in complex neonatal resuscitation and that reduced training increases reliance on potentially non‑resident consultants.
Department of Health and Social Care · National body
Patients not informed of surgical risks in TurkeyEarlier report
“I am concerned that patients travelling to Turkey for this procedure are not being made aware of the risks and the high mortality rate associated with this surgery”
The response stated
“My officials will also be visiting Türkiye shortly to meet with their counterparts. The intention is to discuss the regulatory framework, and the protections that are in place for UK nationals, and to identify concrete areas where the UK and Turkish authorities should work together to reduce the risks to patients in the future.”
Stated timescale: shortly
Raised again
1 year 5 months later
“I am concerned about the fact that we have no evidence to confirm whether Mrs [name redacted] was made aware of the risks and mortality rates associated with any of the surgical procedures she underwent in Turkey.”
Both reports highlight that patients undergoing surgery in Turkey are not being adequately informed of the risks and high mortality rates associated with the procedures.