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
Care Quality Commission · National body
Inaccurate and inconsistent care plan entries and record keepingEarlier report
“The record keeping was inconsistent and lacked detail on general wellbeing.”
The response stated
“The provider has indicated they have also reviewed the quality of their own documentation and care records. In relation to food records, in addition to improved documentation, staff have also received additional training.”
Raised again
1 year 4 months later
“Inadequate record keeping in the Birchwood Care made it difficult to obtain the relevant records for the Inquest and the records obtained were incomplete”
Both reports highlight problems with record keeping that omitted key details about food, fluid intake and general wellbeing. The later report describes the same kind of incomplete records affecting fluid provision and other observations.
Care Quality Commission · National body
Inaccurate and inconsistent care plan entries and record keepingEarlier report
“Records of routine checks on residents are not made. Therefore whilst it was asserted that Mr [name redacted] was checked hourly throughout following the fall there is no evidence that the checks were carried out”
The response stated
“Read and sign sheets have been implemented so that staff read and sign care plans individually when residents are admitted to the home. The aim is that these are completed in a timely manner within 72 hours of a service user arriving, and staff will read and sign them the expectation being within one week. On point of admittance information is given at handover three times a day so that staff are aware of needs of a new resident.”
Stated timescale: within 72 hours of a service user arriving
Raised again
5 years 4 months later
“Inadequate record keeping in the Birchwood Care made it difficult to obtain the relevant records for the Inquest and the records obtained were incomplete”
Both reports identify shortcomings in the documentation of care activities, pointing to inadequate record‑keeping practices. The earlier report notes missing routine‑check logs, while the later report highlights incomplete fluid and pad records that hindered the investigation.
Department of Health and Social Care · National body
Unrestricted online purchase of lethal prescription medicationEarlier report
“- is available to be purchased in lethal quantities from a UK website for less than £5:00, again without restriction.”
The response stated
“I am advised that suicide prevention policy leads in the health system, at the Department of Health and Social Care, Public Health England (PHE), and NHS England and NHS Improvement (NHSEI), are alert to the risk posed by websites promoting suicide methods, and their direction on the use of certain chemicals in completing suicide, including the substance taken by Mrs [name redacted]. These organisations, along with key stakeholders and academics, are looking at what data is available on suicides by this”
Raised again
1 year 9 months later
“- is freely available to be purchased from the internet in lethal quantities for delivery within the UK”
Both reports highlight that a lethal chemical can be bought online in harmful amounts without any seller restrictions. They share the concern that vulnerable individuals face no protection when making such purchases.
Earlier report
“The need for better driver awareness on the use of smart motorways”
The response stated
“Highways England will publish this report shortly”
Stated timescale: shortly
Raised again
1 year 8 months later
“(1) The lack of public understanding regarding the need for them to call National Highways should they identify a problem on the motorway network such as a stationary vehicle.”
Both reports highlight insufficient driver awareness or response to stationary vehicles on smart motorways. The earlier report stresses the need for better awareness and identification, while the later report notes that despite campaigns, road users are not adequately emphasised to report such problems.
East of England Ambulance Service · Ambulance service
Delayed ambulance response to patient deteriorationEarlier report
“(1) At the time of this incident, demand on the EEAS far outstripped the resources available to them.”
The response stated
“In January 2017 we identified ambulance handover times as a key challenge within our performance targets and in order to address this in March 2017 we sought external expertise to reconfigure the handover process, our aim being to reduce handover times to the meet the national standard of 100% within 15 min of arrival, thus releasing ambulance crews in a timelier manner.”
Stated timescale: March 2017
Raised again
4 years 5 months later
“2. There were no emergency ambulances available to assign to this call due to high call demand.”
Both reports describe a situation where demand for ambulance services exceeds available resources, leading to dangerous delays in patient care.
East of England Ambulance Service · Ambulance service
Insufficient ambulance availability leading to delayed emergency responseEarlier report
“That a patient who has suffered a head injury has to wait for over one and a half hours to be conveyed to hospital”
The response stated
“The Trust commissioned a Clinical Capacity Review in 2013 which clearly showed that we did not have enough ambulances to enable the Trust to meet its call demand in certain areas. The findings of this review have been shared with the Clinical Commissioning Groups as additional funding is required.”
Stated timescale: 2013
Raised again
8 years 8 months later
“There were no emergency ambulances to respond to the initial 999 call due to high demand on the service”
Both reports highlight insufficient ambulance resources causing dangerous delays in patient transport. The earlier case concerns head‑injury patients waiting over 1.5 hours, while the later case describes no ambulances available for a 999 call due to high demand.
East of England Ambulance Service · Ambulance service
Insufficient ambulance availability leading to delayed emergency responseEarlier report
“Consistently high levels of outstanding emergency calls and waiting times that far exceed the service's own target response times are likely to put lives at risk.”
The response stated
“we have introduced a process which instigates the release of ambulance crews from queues in A and E departments to attend to patients in the community with life threatening conditions.”
Raised again
5 years 9 months later
“There were no emergency ambulances to respond to the initial 999 call due to high demand on the service”
Both reports highlight that excessive demand on the ambulance service leads to insufficient available resources and dangerous delays in responding to emergencies.
East of England Ambulance Service · Ambulance service
Insufficient ambulance availability leading to delayed emergency responseEarlier report
“heard evidence that this was not an unusual amount of outstanding calls or an unusual level of waiting time. This was the position on the 26”
The response stated
“we have introduced a process which instigates the release of ambulance crews from queues in A and E departments to attend to patients in the community with life threatening conditions.”
Raised again
5 years 9 months later
“There were no emergency ambulances available to assign to this call due to high call demand.”
Both reports highlight that excessive call demand leads to insufficient ambulance availability and dangerous delays in patient care. The core issue is the inability to meet response targets due to high volumes of outstanding calls.
East of England Ambulance Service · Ambulance service
Insufficient ambulance availability leading to delayed emergency responseEarlier report
“That a patient who has suffered a head injury has to wait for over one and a half hours to be conveyed to hospital”
The response stated
“The Trust commissioned a Clinical Capacity Review in 2013 which clearly showed that we did not have enough ambulances to enable the Trust to meet its call demand in certain areas. The findings of this review have been shared with the Clinical Commissioning Groups as additional funding is required.”
Stated timescale: 2013
Raised again
8 years 8 months later
“There were no emergency ambulances available to assign to this call due to high call demand.”
Both reports highlight that insufficient ambulance availability leads to excessively long response times, putting patients at risk. The earlier case involved a head‑injury patient waiting over 1.5 hours; the later case involved a delayed ambulance due to high demand and no available units.
Earlier report
“lack of record keeping on the Ri O of (i) Risk Assessments and details of those persons making the assessments.”
The response stated
“The Trust has Best Practice and Consistency of Recording on Rio for inpatient services, which includes risk assessments. Within 7 hours of admission, a risk assessment is completed by the admitting nurse and doctor. The time and names of the staff completing the assessment are automatically generated and inputted by the electronic patient record system on Rio.”
Stated timescale: January 2015
Raised again
8 years later
“Two types of risk assessments were completed, with no system to ensure that important information is present on both;”
Both reports highlight problems with how risk assessment information is recorded and communicated within the trust. The earlier report cites a general lack of record‑keeping for assessments and observer details, while the later report notes that crucial incident data is omitted from the assessments used by staff.
Department of Health and Social Care · National body
Poor record keeping in missing person investigationsEarlier report
“During the hearing it was noted that on a number of occasions record keeping was poor. This can make continuity of care difficult and it can lead to matters being missed.”
The response stated
“In my opinion action should be taken to prevent future deaths and | believe you and your organisation have the power to take such action.”
Stated timescale: 8 January 2019
Raised again
3 years 8 months later
“there was evidence of poor record keeping, including records not being made, or when they were made not beinq sufficiently detailed and records beinq 3 retrospectively made and changed without the records being clearly marked that the entries were retrospective”
Both reports highlight problems with poor record keeping that can impede continuity of care and lead to missed information.
Home Office · National body
Marac system ineffective for chaotic victimsEarlier report
“The MARAC process was incapable of facilitating protection and resolution of problems for chaotic non engaging individuals.”
The response stated
“We support your recommendation for a national review of how the MARAC system can afford protection and support for these particularly vulnerable complex individuals.”
Raised again
3 years 3 months later
“There is no single point of contact to oversee the collation of all 2 information, to appropriate assess it and to coordinate a structured proactive approach to people with dual or multi diagnosis.”
Both reports highlight shortcomings of the MARAC system in protecting vulnerable individuals. The earlier report focuses on its inability to help chaotic non‑engaging people, while the later report notes the lack of a single point of contact for those with dual or multi diagnoses.