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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Warwickshire County Council · Local authority
Inadequate street lighting at junctionEarlier report
“was concemed that street lighting was not present at this junction”
The response stated
“The County Council has taken very seriously your report and the concerns raised in it. I do hope that through the measures the Council is proposing to implement you, and the family of Mr [name redacted], can be assured of the County Council's commitment to reducing the number of such tragedies in the future.”
Stated timescale: this financial year
Raised again
8 years 6 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 identify inadequate street lighting contributing to road traffic collisions. The earlier case notes lighting was absent at a junction, while the later case describes lighting failure due to a cable fault.
Earlier report
“The target time for the arrival of the ambulance was 8 minutes, this was breached. The ambulance did not arrive for 15 minutes.”
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 6 months later
“had an ambulance for [the deceased] arrived within the target time, the drugs he could have been given by ambulance personnel, and his early transport to hospital, would on a balance of probabilities have saved his life”
Both reports highlight delays in ambulance response leading to missed treatment opportunities.
Earlier report
“[the deceased] was using an online suicide forum, (the forum now appears under the internet address .Through the forum she was able to engage in discussions with other pro-suicide members and obtain advice how to mislead mental health professionals to avoid being sectioned under the Mental Health Act”
The response stated
“The regulator may also undertake thematic teviews of areas of concern, for example, a review into the treatment of self-harm or suicide-related content.”
Raised again
3 years 11 months later
“The concern here is that this site & potentially similar self-harm & suicide "facilitating, or promoting" sites are accessible/available to those, such as BM who are vulnerable, due to their diagnosed, or otherwise mental illness & provided with an outlet/forum to source & acquire information that potentially equips them with the knowledge & means to either complete suicide, or place them in grave/greater danger of doing so.”
Both reports describe an online suicide forum that provides vulnerable individuals with advice on evading mental health interventions and perfecting self‑harm methods.
Earlier report
“(2) Nursing notes documented a risk of falls/mobilisation and action to be taken, but there was no supervision arrangement in place. One to one care had been in contemplation.”
The response stated
“The safety briefing during nursing handover is now to include a verbal handover of the care plans for patients assessed as at risk of falls to alert incoming staff members as to the risk and care plan.”
Raised again
7 years 11 months later
“3. The consequence of (2) was that no falls care plan was completed.”
Both reports highlight shortcomings in managing patients identified as at risk of falls, specifically gaps between documented risk and actual protective actions.
Earlier report
“when they found Mr [name redacted] and rang for an ambulance they were told that due to the ongoing demands on the Ambulance Service that it would be approximately 6 hours before one could attend and transport Mr [name redacted] to hospital”
The response stated
“The government is committed to supporting the ambulance service to manage the pressures it is facing, ensuring that people receive the treatment that they need when they need it. This will be supported by the government investing an additional £3.3 billion in each of 2023-24 and 2024-25 as announced in the Autumn Statement. This will enable rapid action to improve urgent and emergency care performance towards pre-pandemic levels. The NHS will set out detailed recovery plans in the new year.”
Stated timescale: 2023-24 and 2024-25
Raised again
1 year 2 months later
“The ambulance service was called at 11.55 hours on 14 February 2023 and the call was graded as a Category 3 call reinquire a response within 2 hours. The ambulancearrived at 09.30 hours on 15 February 2023. The time between calling the ambulance and the ambulance arriving on scene was in excess of 19 hours.”
Both reports highlight excessively long waits for an ambulance due to service pressures. The earlier case involved a six‑hour delay while the later case involved a delay of over nineteen hours.
Earlier report
“The calls (999) to the ambulance service were properly coded and applied by the call-taker leading to a Green 2 response. This should have led to a vehicle attending within 20 minutes. 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 4 months later
“The time between calling the ambulance service and an ambulance arriving was in excess of 14 hours.”
Both reports highlight excessively long ambulance response times compared to the target times set by the call‑coding system. The underlying issue is insufficient resources or capacity to meet demand.
Earlier report
“The new Governing Governor confirmed that further steps are necessary to improve the management of illicit substance misuse. He confirmed the prison requires CCTV on all wings and airport style scanners - one in reception for prisoners and one in the visitor area.”
The response stated
“G4S does agree with Mr [name redacted] that HMP Birmingham would benefit from CCTV and airport style scanners. It is G4S's understanding that Mr [name redacted] submitted to HMPPS a case for funding in respect of the cost of purchase and installation of CCTV and that this has been approved. The CCTV will therefore be installed at HMP Birmingham in due course.”
Stated timescale: in due course
Raised again
4 years 8 months later
“The report concluded that it was extremely troubling that Mr [name redacted] was able to access and use illicit substances, including Psychoactive Substances, with apparent ease at The Mount, particularly as he lived on a wing for prisoners with substance misuse issues.”
Both reports highlight the ongoing problem of illicit substance misuse within prisons, indicating that drugs remain readily accessible to inmates.
Leeds City Council · Local authority
Unsupervised minors and inaccurate attendance data at Leeds FestivalEarlier report
“Young people aged 16-17 are admitted to the Leeds Festival without any adult supervision.”
The response stated
“Our Clients will host and participate in a Festival S-Map Group which is to hold its first meeting on 28 April 2021. This will be a working group hosted by Festival Republic, including Registered Office - 45 Union Road, New Mills, High Peak, SK22 3EL Registered Number - 13223887 This company is not authorised and regulated by the Solicitors Regulatory Authority representatives from Festival Republic, Leeds City Council, Reading Borough Council, the Police, Forward Leeds and a leading Child Clinician.”
Stated timescale: 28 April 2021
Raised again
2 years 7 months later
“Neither the organiser of the festival (Festival Republic) nor Leeds City Council which licenced the event had accurate information about the number of people under 18 who were attending the festival.”
Same coroner as the earlier report.
Both reports highlight risks to under‑18 attendees at the Leeds Festival due to insufficient safeguards. The earlier report stresses lack of adult supervision; the later report stresses lack of accurate data on how many minors are present.
Lincolnshire County Council · Local authority
Inadequate signage at junction leading to visibility issuesEarlier report
“(I) | received evidence that there were no identifiable defects with the junction. Visibility was good, and all signage and road markings, although a little worn, were said to be clear and unambiguous.”
The response stated
“The latest KSI Review which is about to be completed, has identified the A1 near Toll Bar Road as a site that requires prioritisation for closer investigation following the fatal Sye7s fy INVESTORS WF J INPEOPLE ane.”
Stated timescale: during the New Year
Raised again
6 years 10 months later
“There is a restricted view of the B1190 as a road user approaches the junction. To be certain the B1190 road is clear a road user would be required to stop, however the road signage only requires a road user to give way.”
Both reports highlight that the existing road signage at a junction does not adequately instruct drivers given limited visibility, creating a risk of unsafe crossing. The earlier report notes signage was worn but deemed clear, while the later report argues a give‑way sign is insufficient where a stop is needed.
Earlier report
“when they found Mr [name redacted] and rang for an ambulance they were told that due to the ongoing demands on the Ambulance Service that it would be approximately 6 hours before one could attend and transport Mr [name redacted] to hospital”
The response stated
“The government is committed to supporting the ambulance service to manage the pressures it is facing, ensuring that people receive the treatment that they need when they need it. This will be supported by the government investing an additional £3.3 billion in each of 2023-24 and 2024-25 as announced in the Autumn Statement. This will enable rapid action to improve urgent and emergency care performance towards pre-pandemic levels. The NHS will set out detailed recovery plans in the new year.”
Stated timescale: 2023-24 and 2024-25
Raised again
1 year 1 month later
“2. The Ambulance Service graded [the deceased]'s mother's call to them on the 15th December 2021 as a category 2 call which has two targets as described in evidence, the first being a response time of 20 minutes call time and that 9 out of 10 calls would be responded too within 40 minutes. Yorkshire Ambulance Service were unable to respond to [the deceased]'s call until 2 hours and 26 minutes had passed. Yorkshire Ambulance Service were on their highest level of escalation at that time with significant delays at”
Both reports highlight delays in ambulance response caused by systemic pressures on the ambulance service. The earlier case involved a six‑hour wait due to high demand, while the later case involved a two‑hour‑twenty‑six‑minute delay for a category 2 call during peak escalation.
Earlier report
“the risk assessment requires no consideration of risk factors other than mobility unless 'Step 1' is passed regardless of the number of other risk factors”
The response stated
“my officials have made enquiries with NHS England and NHS Improvement (NHSEI), and the National Institute for Health and Care Excellence (NICE)”
Raised again
2 years later
“The clinicians treating Ms [name redacted] assessed her VTE risk utilising an established algorithm based on national guidance. The assessment was undertaken appropriately but it failed to identify two risk factors”
Both reports highlight that the VTE/DVT risk assessment fails to account for important risk factors beyond mobility. This omission means patients with additional risk factors may not receive appropriate prophylaxis.
Earlier report
“At no time during the two periods of Ms [name redacted] inpatient care was she assessed for venous thromboembolism (VTE) risk in contravention of trust policy.”
The response stated
“A VTE Screening and Assessment Clinical Alert was disseminated across the Trust”
Raised again
6 months later
“It is a matter of concern that ward-based nursing staff do not appear to have been provided with clear and unambiguous guidance as to the circumstances when a risk assessment for Venous Thromboembolism ('VTE') should be undertaken following admission to a ward, and the circumstances in which such risk assessment should be repeated.”
Both reports identify failures in ensuring proper venous thromboembolism (VTE) risk assessment for inpatients. The earlier report notes that no VTE assessment was performed, while the later report highlights absent clear guidance on when such assessments should be done or repeated.