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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University College London Hospitals NHS Trust · NHS body
Unavailable bed leading to delayed patient transferEarlier report
“I am concerned that this backup plan relied on the availability of a bed at a satellite hospital, which was ultimately not available when it was required.”
The response stated
“we will amend it by the end of May 2017 to take account of the normal practice with respect to Westmoreland Street Hospital (WMS) beds which is twice daily updates on the WMS bed state being sent to the main hospital”
Stated timescale: end of May 2017
Raised again
6 years 8 months later
“There was a ten day delay in Ms [name redacted] transfer from the Princess Royal Hospital to UCLH.”
Both reports highlight problems caused by unavailable or unknown bed capacity leading to delayed patient transfers.
Earlier report
“Evidence given at the inquest revealed that there was a delay in an ambulance attending to the deceased and that earlier arrival of an ambulance is likely to mean he would not have died when he did.”
The response stated
“The report raises concerns about ambulance capacity and response times by East of England Ambulance Service NHS Trust (EEAST). In preparing this response, Departmental officials have made enquiries with NHS England and the Care Quality Commission (CQC). I have been informed that the CQC carried out routine engagement with the Trust to review progress against its action plan and to ensure they comply with CQC regulations. More generally, I have been assured that the CQC will continue to have regular”
Raised again
1 year 1 month later
“The ambulance service was called at 2049 on 14 November 2022 and the call was graded as a Category 2 call requiring a response within 40 minutes. The ambulance finally arrived at 0044 on 15 November 2022.”
Both reports highlight delays in ambulance response that contributed to preventable deaths. The earlier report cites systemic capacity issues causing delayed attendance, while the later report describes a specific delayed response due to call grading, off‑load bottlenecks and resource shortages.
Birmingham and Solihull Mental Health NHS Foundation Trust · NHS body
Lack of acute mental health inpatient bedsEarlier report
“Lack of inpatient mental health beds and lack of Psychiatric decisions unit (PDU) spaces: The inquest heard how there was a regional and national lack of inpatient beds and spaces in PDU.”
The response stated
“Consideration is needed urgently to fund further mental health beds and PDU spaces to ensure patients are not kept unattended in extremely busy emergency departments.”
Raised again
10 months later
“Despite recognising Mr [name redacted] needed to be admitted to a psychiatric hospital in June 2023 but there was no bed capacity”
Both reports highlight the ongoing shortage of psychiatric/inpatient mental health beds as a safety concern. They describe the same underlying problem of insufficient bed capacity leading to unsafe patient management.
Birmingham and Solihull Mental Health NHS Foundation Trust · NHS body
Lack of acute mental health inpatient bedsEarlier report
“Between the 16th March 2019 and the 25th April 2019, a bed could not be found for the Deceased even though he had been assessed and fit for detention.”
The response stated
“The CCG has been working closely with both local mental health service providers and the third sector, with the aim of improving the service offer for people experiencing a mental health crisis. Stakeholders are working on designing community based services, which will increase accessibility for those in crisis and their families, to deliver the most appropriate support at the earliest opportunity.”
Raised again
4 years 2 months later
“My principal concern is that the above dates indicate available psychiatric bed capacity in Birmingham and Solihull remains inadequate.”
Both reports highlight a continuing shortage of psychiatric beds in Birmingham and Solihull that prevents timely admission and appropriate care. The later report notes the insufficiency persists despite some actions taken.
NHS England · National body
Inconsistent access to thrombectomy servicesEarlier report
“I heard evidence during this inquest that the availability of thrombectomy is currently variable and dependent on geographical location and timing.”
The response stated
“NHS England is rolling out access to thrombectomy nationally via specialised neuroscience centres over a 5-year period. This commenced in April 2017 with the mapping of services against a specification. Neuroscience centres were asked to develop implementation plans that include being able to move to a fully staffed 24/7 service over 5 years.”
Stated timescale: 5-year period
Raised again
3 years 8 months later
“(1) 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.”
Both reports highlight problems with timely access to thrombectomy services for stroke patients. The earlier report notes geographic and timing variability, while the later report points to a lack of after‑5 pm provision and regional coordination in Lancashire.
Welsh Ambulance Service NHS Trust · Ambulance service
Excessive ambulance handover delays at hospitalsEarlier 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 being experienced at the 2 district general hospitals”
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
6 years 8 months later
“As stated in his evidence at para 45, the handover delays experienced at/around the time that the deceased was awaiting assistance were well in excess of the targets enshrined in the Welsh Health Circular of May 2016.”
Both reports identify ambulance handover delays at hospitals as the cause of delayed ambulance response to patients needing emergency care. The later report reiterates that these delays exceed national targets and affect response times.
Health and Care Professions Council · Local authority
Inadequate paramedic ECG interpretation trainingEarlier report
“one of the paramedics who qualified in 2015 after a 2 year foundation degree gave evidence that he had never had any formal testing on interpretation of 12 lead ECG”
The response stated
“We have taken significant steps within the sector to support the development of paramedic practice. In particular, in March 2018 we determined it necessary to raise the threshold level of entry to the Register to degree level (levels 6/9/10 on the relevant UK qualifications frameworks). The threshold level for entry to the Register for paramedics was changed to degree level for the following reasons: e A large majority of respondents to the public consultation argued that degree level was necess”
Stated timescale: September 2021
Raised again
7 years later
“Paramedic [REDACTED] gave evidence at inquest that she'd never heard of Q waves before and didn't see the ST elevation on the ecg”
Both reports highlight a lack of adequate training in interpreting 12‑lead ECGs among paramedics. The later case shows the same deficiency leading to missed ischemic signs.
Welsh Ambulance Service NHS Trust · Ambulance service
Ambulance handover delays due to bed shortagesEarlier report
“Development of a pan Betsi Cadwaladr University Local Health Board ambulance handover plan to support reducing lost hours to improve performance and availability is still not in force and has been too slow”
The response stated
“The Handover Improvement Plan has been put in place between the Trust, BCU Health Board and NCCU, along with fortnightly meetings chaired by NCCU.”
Stated timescale: December 2022
Raised again
1 year 1 month later
“handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital.”
Both reports highlight problems with ambulance handover processes that affect service availability and timely patient transport. The earlier report notes the lack of a formal handover plan, while the later report observes that existing handover delays are worsening response times.
Welsh Ambulance Service NHS Trust · Ambulance service
Ambulance handover delays due to bed shortagesEarlier report
“unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”
The response stated
“In October 2015 WAST introduced a new clinical response model to implement new ways in which callers to 999 are assessed. This sought to ensure that patients and users of the service received the most appropriate care and a response to suit their individual needs. The changes made clearly identify those patients who require an immediate life-saving response and these patients receive the highest priority response in the fastest possible time. foe) All other patients receive a bespoke”
Stated timescale: October 2015
Raised again
6 years 6 months later
“handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital”
Both reports describe handover delays in emergency departments that prevent ambulances from being freed up for other calls.
Earlier report
“This risk is due firstly to a lack of available staff to provide the required operational hours and secondly to handover delays at hospitals across the region.”
The response stated
“SECAmb had planned for 2370.1 WTE by 31 March 2023.”
Stated timescale: 31 March 2023
Raised again
8 months later
“As stated in his evidence at para 45, the handover delays experienced at/around the time that the deceased was awaiting assistance were well in excess of the targets enshrined in the Welsh Health Circular of May 2016.”
Both reports identify handover delays at hospitals as a factor that prolongs ambulance response times and endangers patient safety. The earlier report also cites staff shortages, while the later report focuses solely on handover delays exceeding Welsh targets.
Earlier report
“improvements at Derriford Hospital had been made following the events during which a central venous line was misplaced into an artery”
The response stated
“The ICM training programme requires trainees to understand and recognise complications from line insertions however, the number of procedures required for sign off is not mandated nor do we believe that this type of complication would be prevented if this were the case.”
Raised again
7 years 9 months later
“Absence of a national policy on the placement of CVC's”
Both reports concern risks associated with central venous catheter placement. The earlier report focuses on preventing misplacement through local improvements, while the later report highlights the lack of a national standard policy.
Warwickshire County Council · Local authority
Inadequate street lighting at junctionEarlier report
“There are no signs warning pedestrians or cyclists of the dangers of using the road. There are no street lights. The speed limit on the road is 7Omph. There is no barrier or other protective features between the vehicular traffic and pedestrians”
The response stated
“The feasibility study is expected to be completed by the end of September 2014.”
Stated timescale: end of September 2014
Raised again
9 years 8 months later
“The street lighting along Trinity Road, Piccadilly, nr Kingsbury was not illuminated at the time of the Road Traffic Collision due to a fault.”
Both reports highlight inadequate street lighting as a safety hazard for pedestrians and cyclists. The earlier report notes a general absence of lighting on the A444, while the later report describes a specific lighting fault on Trinity Road.