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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His Majesty's Prison and Probation Service · National body
Lack of basic first aid training and CPR among prison officersEarlier report
“Some Prison staff had not received any cardiopulmonary resuscitation training. Either as part of initial training or any refresher training.”
The response stated
“The Governor at HMP New Hall has reviewed the band/grade and number of staff who need to be trained in first aid, and the number of such staff required on duty at times throughout the day. The prison currently has 40 staff trained in FAW and 48 in EFAW, and these numbers are considered to be sufficient to ensure that an appropriate response can be provided in any emergency situation that may arise at any time.”
Raised again
5 years 3 months later
“It is not mandatory for prison officers to have basic first aid training (which includes the provision of CPR) which is in-date.”
Both reports highlight insufficient or outdated cardiopulmonary resuscitation/first‑aid training among prison staff. The earlier report notes staff lacking any CPR training, while the later report points out that existing training is not kept current.
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
8 years 10 months later
“It is not mandatory for prison officers to have basic first aid training (which includes the provision of CPR) which is in-date.”
Both reports highlight the lack of mandatory, up‑to‑date basic first aid and CPR training for prison officers. They concern the same hazard: insufficient life‑saving training for staff with prisoner contact.
Department of Health and Social Care · National body
Insufficient inpatient bed capacity leading to delayed discharges and patient harmEarlier report
“My concern however is that had he needed admitting it is apparent no beds would have been available at Green Lane Hospital Devizes when an enquiry was made on 6 July 2014 by North Wiltshire Intensive Services.”
The response stated
“The Trust Board closely monitors bed pressures and out of area placements and is continually working with its Commissioners and NHS England to manage the situation optimally.”
Raised again
8 years 9 months later
“In May 2023, when it was felt Mr [name redacted] required an informal admission into hospital, no beds were available.”
Both reports highlight that patients needing psychiatric admission could not be accommodated because no hospital beds were available. The earlier case concerned Green Lane Hospital in Devizes, while the later case concerns bed shortages in Cornwall.
Earlier report
“long delays in ambulance response to Category 2 calls create a risk that other deaths will occur in the future”
The response stated
“published our Delivery plan for recovering urgent and emergency care services' which aims to deliver sustained improvements in waiting times, including to reduce Category 2 response times to 30 minutes on average this year”
Stated timescale: 2023/24
Raised again
8 months later
“The category 2 call target (18minute average response and 95th percentile a 40minute response) was breached and the ambulance arrived 1 hour and 6 minutes after the first call.”
Both reports highlight that prolonged ambulance response times for Category 2 calls pose a risk of avoidable deaths. They differ in focus: the earlier report stresses persistent systemic delays, while the later report notes a specific breach and inadequate detection of worsening conditions.
East of England Ambulance Service · Ambulance service
Insufficient ambulance availability leading to delayed emergency responseEarlier report
“Consistently high levels of outstanding emergency calls and waiting times that far exceed the service's own target response times are likely to put lives at risk.”
The response stated
“we have introduced a process which instigates the release of ambulance crews from queues in A and E departments to attend to patients in the community with life threatening conditions.”
Raised again
7 years 2 months later
“Availability of ambulances to carry out transfers in a timely manner, in urgent cases, between NHS Hospitals and in responding to 999 and 111 calls in the community.”
Both reports highlight insufficient ambulance availability leading to dangerous delays in emergency care.
East of England Ambulance Service · Ambulance service
Insufficient ambulance availability leading to delayed emergency responseEarlier report
“There were no emergency ambulances available to assign to this call due to high call demand.”
The response stated
“In liaison with East of England Ambulance Service, agree a process to support timely ambulance transfers and early notification of when an ambulance is required”
Raised again
1 year 5 months later
“Availability of ambulances to carry out transfers in a timely manner, in urgent cases, between NHS Hospitals and in responding to 999 and 111 calls in the community.”
Both reports highlight insufficient ambulance availability leading to dangerous delays in patient care. The earlier case concerns lack of ambulances for emergency calls, while the later case focuses on delays in inter‑hospital transfers and 999/111 responses.
East of England Ambulance Service · Ambulance service
Insufficient ambulance availability leading to delayed emergency responseEarlier report
“There were no emergency ambulances to respond to the initial 999 call due to high demand on the service”
The response stated
“In liaison with East of England Ambulance Service, agree a process to support timely ambulance transfers and early notification of when an ambulance is required”
Raised again
1 year 5 months later
“Availability of ambulances to carry out transfers in a timely manner, in urgent cases, between NHS Hospitals and in responding to 999 and 111 calls in the community.”
Both reports highlight insufficient ambulance availability leading to dangerous delays in emergency response. The earlier report cites no ambulances for an initial 999 call due to high demand, while the later report stresses untimely ambulance transfers for urgent hospital transfers and 999/111 calls.
Earlier report
“A publication such as , that contains detailed instructions as to how to end a human life, is available to be purchased online without restriction.”
The response stated
“I am advised that suicide prevention policy leads in the health system, at the Department of Health and Social Care, Public Health England (PHE), and NHS England and NHS Improvement (NHSEI), are alert to the risk posed by websites promoting suicide methods, and their direction on the use of certain chemicals in completing suicide, including the substance taken by Mrs [name redacted]. These organisations, along with key stakeholders and academics, are looking at what data is available on suicides by this”
Raised again
3 years later
“[REDACTED] is available to anyone to purchase online, directly from the company.”
Both reports concern the unrestricted online availability of instructional material that enables individuals to end their own lives. The later report adds detail about making deaths appear natural but the core hazard remains the same.
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
8 years 7 months later
“There was a significant delay in offloading patients at hospitals, which tied up resources and meant they were unable to respond to emergency calls.”
Both reports identify delays in offloading patients at hospitals as a factor that ties up ambulance resources and prolongs response times. The earlier report notes this as a general issue affecting availability, while the later report links it directly to a 3‑hour‑18‑minute response delay.
Earlier report
“The failure by the ambulance dispatcher to dispatch an ambulance closer to the deceased's location”
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
8 years 7 months later
“The delay in the ambulance dispatch prevented Mr [name redacted] receiving medical treatment and further psychiatric assistance.”
Both reports highlight problems with ambulance dispatch timeliness affecting patient outcomes. The earlier report cites a systemic fault causing ambulances not to be sent close enough, while the later report notes dispatch delays due to high demand preventing timely treatment.
Earlier report
“In the event, the vehicle did not arrive for 2 hours 8 minutes.”
The response stated
“NWAS is currently exploring better ways to minimise lengthy waits during high demand periods and has also secured funding for 400 additional frontline staff and 60 new vehicles which | hope will assist in alleviating some of these pressures.”
Raised again
7 years 7 months later
“The ambulance response time of 3 hours and 18 minutes has likely affected the outcome.”
Both reports highlight excessively long ambulance response times caused by insufficient resources and staffing levels.
Earlier report
“The previous incident in which [the deceased] had attempted to take his own life in very similar circumstances on the ward was not clearly entered on the risk assessments used by staff and therefore not known to a number of those responsible for his care”
The response stated
“The Trust has undertaken a Serious Incident Investigation following the death of [the deceased]; the report was shared at the inquest and I can confirm that the action plan developed in response to the RCA investigation has been completed.”
Raised again
1 year 5 months later
“At least one member of staff was unaware that [the deceased] had described himself to staff in May 2020 as looking for an opportunity to take his own life if it arose”
Both reports highlight that staff were not informed of a patient's previous self‑harm attempt, which hindered risk assessment and care planning. The earlier case concerns missing data in risk assessments; the later case concerns missing communication of a recent attempt description.