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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Pennine Care NHS Trust · NHS body
Incompatible electronic records hinder mental health information sharingEarlier report
“There does not appear to be a reliable and consistent method of sharing medical records and information between the two Trusts.”
The response stated
“The joint SOP which is scheduled to be trialled in August 2020 will apply to all patients within PCFT's older peoples' mental health inpatient wards. Both organisations will continue to work in partnership to identify, agree and establish working parameters for the Digital Health Team at TGH to support the physical health needs of older people receiving mental health care and treatment on Summers & Hague wards, of which Mr [name redacted] was a patient. The offering of Digital Health services will be conducted”
Stated timescale: August 2020
Raised again
3 years 3 months later
“It is a matter of concern that Mental Health Trusts and Acute Trusts operate different (apparently incompatible) electronic records systems.”
Both reports highlight problems with sharing clinical information between different healthcare providers due to incompatible or unreliable record‑keeping systems. The earlier report focuses on poor record sharing between two specific trusts, while the later report notes a broader incompatibility between mental health and acute trust electronic records.
Department of Health and Social Care · National body
Ambulance delays for frail elderly hip fracture patientsEarlier report
“such delays were not unusual and were still occurring.”
The response stated
“we are maintaining this additional capacity in 2024/25. This is alongside the delivery of new ambulances and specialist mental health vehicles. With more ambulances on the road, patients will receive the treatment they need more swiftly.”
Stated timescale: 2024/25
Raised again
8 months later
“such delays were not unusual throughout December due to demand and resources.”
Same coroner as the earlier report.
Both reports highlight that ambulance service delays due to demand and resource shortages are not unusual and affect frail elderly patients awaiting care.
Earlier report
“(1) Evidence given at the inquest revealed that there was a delay in Mr. [name redacted] being transferred from the ambulance into the emergency department at the James Paget hospital as they had no space for him to be transferred into.”
The response stated
“the Integrated Care Board (ICB) responsible for JPUH, Norfolk and Waveney ICB, provided a comprehensive response on 3 February 2023 which included information on the improvements being made locally, and details of a serious incident investigation report following Mr [name redacted]' death.”
Stated timescale: 3 February 2023
Raised again
6 months later
“1. The inquest heard that the long wait for an ambulance and prolonged delay in the Emergency Department were due to demand on services and resources available.”
Both reports describe delays in ambulance handovers caused by insufficient space in the emergency department due to high demand and poor patient flow.
Earlier report
“Different health care departments have different patient care records and the departments did not communicate with one another.”
The response stated
“We understand from the request that the discharge care plan was not followed, and this was not recognised. This is an issue of health and social care coordination and management.”
Raised again
2 years 8 months later
“different health organisations use different digital systems that do not communicate with each other.”
Both reports highlight that separate health organisations maintain independent patient record systems that do not share information, hindering communication.
Department of Health and Social Care · National body
Lack of action on high clozapine blood test resultsEarlier report
“In February 2019 a blood test result confirmed that Mr [name redacted] had a high level of clozapine in his blood. This was not acted upon and no further blood test was taken. The clozapine dose was not adjusted as it should have been.”
The response stated
“There is a system in place whereby anomalous results received are escalated to the Consultant, for example, via the Multi-Disciplinary Team meeting, the administrative staff in receipt of paper results or by junior medical staff who have checked electronic investigations; however on this occasion it appears that this failed. We have therefore put in place an additional control whereby our Information Team will send a report to the pharmacy Clozapine Lead of any results >600 so that these can be”
Raised again
2 years 11 months later
“There was no system for highlighting high clozapine results in the rio notes which are routinely used by all clinicians.”
Same coroner as the earlier report.
Both reports highlight the absence of a reliable system to ensure that elevated clozapine blood test results are recognised and acted upon. The earlier report focuses on escalation of results to consultants, while the later report stresses the need for highlighting high results in clinical notes.
Betsi Cadwaladr University Health Board · NHS body
Ambulance delays leading to resource unavailabilityEarlier report
“ambulance delays/admission to ED/availability of resources/patient flow”
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.”
Stated timescale: October 2015
Raised again
6 years 1 month later
“unacceptably lengthy delays remain such as in the case of [the deceased]”
Both reports highlight ongoing ambulance delays affecting patient flow into emergency departments.
Betsi Cadwaladr University Health Board · NHS body
Ambulance delays leading to resource unavailabilityEarlier report
“That notwithstanding changes which have been made by both BCuHB and WAST, there remain wholly 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
“has considered your concems in relation to the following issues outlined in the two notifications: Flyst Regulation 28 Notification Part 1 ~ That not withstanding changes which have been made by both BGUHB and WAST, there remain wholly unacceptable delays with patients belng kept waliing for long periods in ambularices and ambulance resources consequences being unavailable for allocation te other calls as a result of which the risk of future”
Raised again
6 years 10 months later
“Evidence was heard at the Inquest that the initial delays experienced by [the deceased] whilst awaiting an ambulance and waiting in the rear of the ambulance possibly contributed indirectly to her existing frailty.”
Both reports highlight ongoing patient flow problems that cause ambulance delays and prolonged waits in emergency departments. The earlier report focuses on internal hospital flow issues, while the later report attributes the flow deficit to social care deficiencies.
Welsh Ambulance Service NHS Trust · Ambulance service
Delayed ambulance response to critically unwell patientEarlier report
“There was a delay of some 3 hours in sending an ambulance to Mr [name redacted] when it was clear that his clinical picture was rapidly deteriorating.”
The response stated
“The Trust acknowledges your concerns regarding our lack of resourcing, which meant that there was a significant delay in attending to a critically unwell patient.”
Raised again
4 years 9 months later
“the delay in the attendance of the ambulance is significant and unacceptable.”
Both reports highlight a dangerous delay in ambulance attendance caused by insufficient resources. They describe the same underlying hazard of delayed response to deteriorating patients.
College of Policing · National body
Untrained police control room staff lack recognition of acute behaviourEarlier report
“College of Policing issued a training package at the end of 2016 to all Police Forces on ABD.”
The response stated
“the College will work with police stakeholders through the NPCC First Aid Forum and the national clinical governance panel to reflect this learning outcome in Module 2, the refresher training module for front line staff. This will ensure that this training is given to all front line officers. This amendment will be made as part of the wider scheduled review of the FALP following the release of updated guidance by the UK Resuscitation Council in 2020.”
Stated timescale: 2020
Raised again
3 years 8 months later
“During the course of the Inquest, evidence was heard about the understanding and training in relation to Acute Behaviour Disturbance (ABD). All of the officers who had received their College of Policing Personal Safety Training had been trained on the ABD module within that package.”
Both reports concern the College of Policing's training on Acute Behavioural Disturbance (ABD) and its effectiveness in enabling officers to recognise ABD in practice.
University Hospitals Birmingham NHS Foundation Trust · NHS body
Lack of integrated multidisciplinary care across sitesEarlier report
“There is a general concern that all sites with the Trust are not integrated and are not following the same protocols.”
The response stated
“The Trust now have in place a single MDT to support decision making in oesophago- gastric cancer care, however for the purposes of care delivery there are currently two teams. The work to establish a single service for all aspects of care is in train and will be in complete by June 2019.”
Stated timescale: June 2019
Raised again
4 years 5 months later
“Furthermore, the approach appears fragmented increasing the risk of mis-communication or mis-understanding.”
Both reports highlight a lack of integrated, consistent multidisciplinary care across the Trust’s sites, leading to fragmented processes and communication risks.
UK Health Security Agency · National body
Inaccurate risk assessment of Mycobacterium Chimaera infection from heater-coolEarlier report
“It is apparent that it is important that the nationally recognised level of the risk of developing Mycobacterium Chimaera from exposure to a heater cooler unit is accurate”
The response stated
“PHE will further update the risk estimates and ensure that these are published by September 2021”
Stated timescale: September 2021
Raised again
2 years 3 months later
“There is an inconsistency between - Previous Public Health England and current NHS guidance only to notify patients undergoing surgery from January 2013 of the risk of Mycobacterium Chimaera infection”
Both reports concern the accuracy and timeliness of information provided to patients about the risk of Mycobacterium Chimaera infection from heater‑cooler units. They differ in focus: the earlier report stresses the need for up‑to‑date risk estimates, while the later report highlights a mismatch between the January 2013 notification start date and evidence of earlier infections.
South East Coast Ambulance Service · Ambulance service
Insufficient ambulance resources leading to delayed responseEarlier report
“the ambulance was so delayed in its response to Mr [name redacted]”
The response stated
“We are currently working with our commissioners in a jointly commissioned demand and capacity review, intended to better align our resource requirements to the demands on our service, particularly in the light of the newly introduced Ambulance Response Programme standards.”
Raised again
5 years 4 months later
“SECAMBS is regularly operating at Stage 4 of its Surge Management Plan, meaning that demand for the service is significantly outstripping available resources and the service is not capable of responding to calls within target timeframes.”
Both reports highlight delays in ambulance response due to insufficient resources relative to demand.