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.
563 links
South East Coast Ambulance Service · Ambulance service
Insufficient ambulance resources leading to delayed responseEarlier report
“there were insufficient resources to deal with the high number of calls on this day which meant that these two ladies were left on the floor for over 7 hours”
The response stated
“We are aiming to recruit an additional 300 ambulance crew members, so we will have more resources that we can call upon for times of maximum demand.”
Stated timescale: next three years
Raised again
5 years later
“SECAMBS is regularly operating at Stage 4 of its Surge Management Plan, meaning that demand for the service is significantly outstripping available resources”
Both reports highlight that insufficient ambulance resources lead to dangerous delays in patient care. The earlier case describes a specific incident where low staffing left patients unattended for hours; the later warning notes routine operation at surge capacity that risks repeating such delays.
Ministry of Justice · National body
Unattended blade in cell overnightEarlier report
“Despite this history and the known risk he was permitted under the prevailing rules at HMP Wakefield to be in possession when alone in his locked cell overnight.”
The response stated
“During the inquest, you heard evidence that following Mr [name redacted] death, the Governor ordered a review of the prison's local policy and confirmed that it sets out the action that must be taken when staff issue prison , which includes a risk assessment and staff ensuring they check that the blades are present when the razor is returned.”
Stated timescale: spring of 2023
Raised again
8 months later
“Mr [name redacted] had a history of self-harming [REDACTED]. Nonetheless, he was permitted [REDACTED] in his possession when alone in his cell.”
Same coroner as the earlier report.
Both reports concern prisoners being allowed to keep a potentially harmful object (a blade or similar item) in their cells despite a known risk of self‑harm. The specific object and manner of harm differ slightly, but the core hazard is the same.
Betsi Cadwaladr University Health Board · NHS body
Ambulance delays leading to resource unavailabilityEarlier report
“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
“we have made progress against key actions which are all identified in the attached action plan”
Stated timescale: 2016-05-05
Raised again
6 years 10 months later
“It seems that patient flow i.e. those patients who are ready to be discharged from hospital but are unable to be discharged due to insufficiencies in social care means that ambulances are unable to offload patients into the Emergency Department”
Both reports highlight ambulance delays caused by patients being unable to move through the hospital system, specifically due to patient flow and discharge bottlenecks.
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 1 month later
“The inquest heard evidence that under the Department of Health's Ambulance Response time criteria, a category 2 call should have an average response time of 18 minutes and be within 40 minutes in 9 out of 10 cases.”
Both reports highlight that ambulance response times exceeded the required targets, indicating a systemic delay in getting ambulances to patients. The earlier report concerns an 8‑minute target breached with a 15‑minute wait, while the later report concerns category‑2 targets (average 18 min, 90 % within 40 min) breached with waits over an hour.
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 as a result of which the risk of future deaths continues.”
The response stated
“we have made progress against key actions which are all identified in the attached action plan”
Stated timescale: 2016-05-05
Raised again
6 years 10 months later
“Following the fall at home on 7th June 2022 WAST were contacted at 05:23. An ambulance arrived 17 hours 22 minutes later. On arrival at Ysbyty Glan Clwyd [the deceased] then waited in the ambulance for 12 hours 4 minutes before being handed over to nursing staff.”
Both reports highlight prolonged ambulance waits that tie up resources and increase mortality risk.
NHS England · National body
Missing mental health assessment in police custodyEarlier report
“Despite this, no psychiatrist visited or attempted to visit Mr. [name redacted] in custody which it was stated in evidence was the usual practice of the team.”
The response stated
“implementing a documented and recognised system within our bed management team for all such calls which includes phonetic spelling and other controls to ensure a consistent approach to this matter”
Stated timescale: late September 2019
Raised again
3 years 11 months later
“During his time in police custody, it was identified by the custody sergeants that [the deceased] required a face to face assessment by the mental health practitioner. This did not happen.”
Both reports highlight that a mental health assessment was not carried out for a person while they were in police custody, despite indications that one was needed. The earlier case involved a missing psychiatrist visit; the later case involved a missing face‑to‑face assessment by a mental health practitioner.
Earlier report
“Despite a number of measures being undertaken by the North West Ambulance Service, the delay in paramedics attending Category 2 calls has not been resolved to within target ranges because there are residual staff and emergency vehicle shortages.”
The response stated
“The North West Ambulance Service (NWAS) lead commissioners, representatives from the local health system and NHS England have developed a 6-point winter improvement plan concentrating on key actions to assist in improving performance levels for 999 and Urgent and Emergency Care.”
Raised again
1 year 1 month later
“long delays in ambulance response to Category 2 calls create a risk that other deaths will occur in the future.”
Both reports highlight that delays in ambulance response to Category 2 calls pose a risk of further deaths. The underlying cause is insufficient staff and emergency vehicle resources leading to persistent missed response targets.
His Majesty's Prison and Probation Service · National body
Inadequate ACCT training leading to incomplete documentationEarlier report
“I am concerned that this does not go far enough to change past practice and ensure that relevant information is shared, in light of the prison staff's lack of access to System One records”
The response stated
“Following the inquest I have reflected and reviewed healthcare processes and there have been discussions within the healthcare team. Going forward we will ensure that the Local Operating Procedures (LOPs) are embedded, with senior management undertaking audits, to ensure that where any relevant risks and triggers are identified, we will share information with the prison in the following ways:- - Update on C nomis - entry to be made by allocated healthcare staff - Update the ACCT document and”
Raised again
5 years 5 months later
“In evidence it was clear that the ACCT document was the only written document used for sharing information between the healthcare staff employed by the NHS trust and the prison security staff”
Both reports highlight that information vital for ACCT assessments is not shared because healthcare and prison staff use separate systems (SystemOne vs NOMIS) and rely solely on the ACCT document. The later report stresses the same lack of cross‑system review, while the earlier one adds concerns about trigger factors and staff familiarity.
Earlier report
“There are particular difficulties with securing a complete sequence of employment and the associated references and confirmation about concerns for fitness to practice of long term locum doctors who may have gaps between jobs or worked abroad”
The response stated
“time. We also review both policy and practice in relation to employment checks on a regular basis and as changes to the national requirements are introduced.”
Stated timescale: January 2015
Raised again
8 years 9 months later
“The Trust had relied on long term locum consultants, leading to some short-term gaps in provision.”
Both reports highlight problems arising from the use of long‑term locum doctors, specifically gaps in employment history and continuity of care.
Earlier report
“Mr [name redacted] was aged 72. The Community Mental Health Team advised on 18/10/18 that he required an immediate admission for inpatient mental health treatment for his own safety. However, this could not happen as no bed was available within the area.”
The response stated
“NHS. England has committed to eliminating. the practice. of sending people out of-area for non-specialist acute inpatient:care due to”
Stated timescale: 2021
Raised again
4 years 2 months later
“there are about 12 hours of delay following a 22.00 s2 Mental Health Act assessment built into the system if there is no bed.”
Both reports highlight that a shortage of inpatient mental health beds prevents timely admission or leads to dangerous delays. The earlier case concerns immediate admission being impossible due to no local bed, while the later case describes a built‑in delay after assessment when no bed is available.
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
2 years 3 months later
“THERE WAS NOWHERE FOR THE DRIVER OF THE FIRST VEHICLE TO PARK SAFELY”
Both reports highlight the danger of having nowhere safe to stop because smart motorways lack a hard shoulder.
Earlier report
“The Out of Hours GP, EE cid not have access to either the mental health or GP records”
The response stated
“NHS England proposes to disseminate a reminder to GPs to safety net urgent mental health referrals, reflecting in particular the inherent vulnerabilities associated with patients with mental health problems who may find it more difficult to engage with specialist mental health services when they are acutely unwell, and furthermore consider giving a patient written guidance on what to expect and when following a referral, given the impact mental health problems have on concentration and hence memory”
Raised again
5 years 3 months later
“it is either not possible to access information held by a GP practice out of GP surgery hours or where it is possible to do so that is only available if the GP is in the same geographic area as the”
Both reports highlight that general practitioner records are not accessible to clinicians outside normal surgery hours or across geographic boundaries. This gap prevents timely sharing of critical patient information during crises.