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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Department of Health and Social Care · National body
Lack of timely reporting and registration of food allergy fatalitiesEarlier report
“The Head of Incidents at the FSA informed the court that the FSA has started work on a reporting platform for allergic reactions, but needs access to information on all fatalities if it is to have effective oversight of food safety.”
The response stated
“The FSA has started work on a project designed to collect more reported data on food-based allergic reactions that do not result in death. Work on this project is progressing despite some disruption due to the COVID-19 pandemic. We are currently undertaking discovery work with people with allergies to understand the type of information they could provide and the data that the FSA could receive on allergic reactions. This will enable us to assess expectations and the perceived usefulness of such”
Stated timescale: end of next year
Raised again
2 years 4 months later
“In my opinion action should be taken to consider establishing a national reporting system which includes timely reporting to local authority and FSA and maintenance of a register of fatalities and their investigations, and consideration be given to investigating the feasibility of wider access to AAIs.”
Both reports highlight the lack of a timely national reporting system and register for allergy-related fatalities, calling for improved information sharing between local authorities, coroners and the FSA.
South East Coast Ambulance Service · Ambulance service
Insufficient ambulance resources leading to delayed responseEarlier report
“(1) That there were insufficient resources to deal with the high number of calls on”
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
4 years 9 months later
“There is a risk of a future reoccurrence of the situation which arose on 10 May 2022, namely a deficit in operational hours provided by SECAMBS leading to delayed response times compromising patient safety.”
Both reports highlight that a shortage of staff or resources leads to dangerous delays in ambulance response and patient care. The earlier case describes patients left unattended for hours due to insufficient resources; the later case warns of delayed response times from a deficit in operational hours caused by lack of staff.
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 1 month later
“a deficit in operational hours provided by SECAMBS leading to delayed response times compromising patient safety”
Both reports identify delayed ambulance response times as a safety risk. The earlier case focuses on a single incident due to call grading and follow‑up failures; the later case highlights systemic staff shortages and hospital handover delays causing ongoing delays.
Earlier report
“target response times are still routinely not being met nationally.”
The response stated
“The NHS will also set out detailed recovery plans in the new year, including plans to improve ambulance response times and improve A&E waiting times.”
Stated timescale: new year
Raised again
9 months later
“a deficit in operational hours provided by SECAMBS leading to delayed response times compromising patient safety.”
Both reports identify delayed ambulance response times as a safety concern. The earlier report notes nationwide missed targets, while the later report links delays to staff shortages and hospital handovers.
Department of Health and Social Care · National body
Insufficient ambulance availability leading to delayed responseEarlier report
“I remain very concerned about resource issues for this ambulance service.”
The response stated
“The need for an urgent review of resources to reduce the risk of future deaths”
Stated timescale: 2016/17 contract
Raised again
6 years 8 months later
“I am concerned that there are insufficient ambulance service resources to meet the needs of the City of Milton Keynes.”
Both reports highlight a lack of sufficient ambulance resources leading to delays in patient care. The core concern is that the ambulance service cannot meet demand because ambulances are unavailable.
Birmingham and Solihull Mental Health NHS Foundation Trust · NHS body
Lack of risk assessment for missing personsEarlier report
“No formal risk assessment was undertaken and staff failed to appreciate what drugs she had available to her”
The response stated
“We will take action with regards to managing the breach of policy The Senior Nurse for Professional Standards issued a formal practice alert on 12th September 2016 to registered and unregistered clinicians in our crisis and community teams to reinforce the requirements for: Clinical Risk Assessments regarding risk of self-harm and/or suicide; Risk Assessments with regard to medicines management and self-medication; Safe administration of medication as per current Medicines Code and NMC Code.”
Stated timescale: 12th September 2016
Raised again
6 years 6 months later
“When Mr [name redacted] was first reported as missing no risk assessment was undertaken about his level of risk to himself”
Same coroner as the earlier report.
Both reports highlight a lack of proper risk assessment concerning individuals at risk of self‑harm. The earlier case involved medication availability while the later case involves missing‑person risk assessment.
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
3 years 3 months later
“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.”
Both reports highlight a shortage of inpatient mental health beds as a core safety issue. The later report adds concern about insufficient Psychiatric Decision Unit spaces and resulting risks in emergency departments.
Department of Health and Social Care · National body
Overcrowded emergency department leading to delaysEarlier report
“The inquest heard evidence that on admission to Stepping Hill Hospital the Emergency Department was extremely busy due to the volume of patients in the department.”
The response stated
“The new approach will incorporate two elements: - Implementation of the new national NHS 111 First Initiative, which will ask patients to call 111 prior to attending an Emergency Department - A new pre-Emergency Department triage and streaming system Both of these will help ensure patients are streamed or referred to the most appropriate service for their needs. This will include a wide range of community and acute-based services and will ensure only patients who need an Emergency Department go”
Stated timescale: April 2022
Raised again
2 years 5 months later
“The Emergency department staff gave evidence that they regularly have too many patients in the department and cannot find space to safely allow ambulances to transfer patients into their care and then leave.”
Both reports identify emergency department overcrowding due to insufficient bed capacity as a core safety issue. The earlier report focuses on patients being treated in corridors and delayed transfers, while the later report highlights ambulance handover delays caused by the same overcrowding.
Earlier report
“The timeliness of GMP's response, against a backdrop of lack of adherence to/use of the escalation and call grading protocols.”
The response stated
“The Operational Communications Branch (OCB) has undertaken a review of its Escalation Policy. The intention of this review, which is in its final stages, is to ensure the OCB works effectively with Divisions to enhance its ability to effectively identify areas of risk and then effectively manage the allocation of patrols to address that risk. In cases when it becomes apparent that resources are unavailable for allocation, the Escalation Policy will ensure the incident is brought to the attention”
Stated timescale: final stages
Raised again
8 years 2 months later
“In relation to the grading of the lncid.ent relating to the Deceased, which was reported at 18.09 hours on the 29th of January 2021, the Incident was graded correctly as a Grade 2 Priority Response with a response time of 1 hour but a police officer only attended more than 8 hours after the report of the Incident”
Both reports highlight delays in police attendance despite correct incident grading, pointing to shortcomings in response policies or protocols.
Home Office · National body
Unlicensed DNP weight loss drug toxicityEarlier report
“[the deceased] took an overdose of a drug called 2,4 Dinitrophenol. This is a compound that | heard is used as an unlicensed weight loss drug”
The response stated
“The NFCU continues to take steps to tackle the marketing and sale of 2,4 dinitrophenol. Owing to the dangers it poses to the public tackling the illegal sale of DNP is one of the unit's highest priorities and will continue to be so. Whilst we have had some success in this area and there are encouraging signs that this is beginning to have a deterrent effect on both suppliers and potential users of the chemical there is still work to be done and we will continue to direct resource at this issue.”
Raised again
5 years 10 months later
“DNP is a highly toxic substance. It should never be used for human consumption. Nevertheless some people do use it to assist with weight loss and body-building.”
Both reports highlight the danger of 2,4‑dinitrophenol being used as an unlicensed weight‑loss agent and the risk posed by its continued availability.
Durham County Council · Local authority
Accessible bridge parapet and railingEarlier report
“(1) the bridge's parapet and railing is accessible to pedestrians on the bridge;”
The response stated
“the dissemination of information relating to community mental health and wellbeing support services via network channels including local GP's, schools, the Area Action Partnership (AAP) and local workplaces”
Raised again
1 year 3 months later
“(1) the bridge's parapet and railing is accessible to pedestrians on the bridge;”
Same coroner as the earlier report.
Both reports identify that the bridge's parapet and railing is accessible to pedestrians, allowing people to climb over and jump.
Earlier report
“Evidence was given that there are no procedures in place for such communications between the health services and Trading Standards in cases of non fatal anaphylactic reactions.”
The response stated
“Our revised anaphylaxis draft protocol includes a referral form to inform Trading Standards of cases of anaphylactic reaction as a result of consuming food from commercial premises.”
Stated timescale: 23 March 2018
Raised again
4 years 11 months later
“- To establish a robust system of capturing and recording cases of anaphylaxis, and specifically, fatal and near-fatal anaphylaxis, to provide an early warning of the risk posed to allergic individual by products with undeclared allergen content.”
Both reports concern the risk of undeclared allergens causing anaphylactic reactions and the need for better reporting of such incidents to authorities.