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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NHS England · National body
Adhesions leading to small bowel obstructionEarlier report
“Independent expert evidence was heard that indicated that the deceased likely had band adhesions - a known complication of her past abdominal surgery.”
The response stated
“The Trust have a monthly joined Emergency Medicine and Surgical teaching session. This is a platform for these Departments to present and discuss cases they face in order to improve patient safety continuously. It is important to note that cases surrounding acute abdomen are frequent and therefore often require discussion of the AAPP. The AAPP is a feature of these discussions each time a relevant case is discussed.”
Stated timescale: ongoing
Raised again
1 year 7 months later
“There are other clinics nationally who may be offering patients Preoperative Progressive Pneumoperitoneum (PPP) to patients who have a history of adhesional small bowel obstruction (ASBO).”
Both reports concern abdominal adhesions leading to small bowel obstruction. The earlier case involved spontaneous band adhesions causing obstruction, while the later case warns that a procedure can exacerbate adhesions and cause obstruction.
Department of Health and Social Care · National body
Delayed discharge due to lack of suitable care home placementEarlier report
“The inquest heard that Mr [name redacted] could have been discharged from 19th September when he was medically optimised. However he remained in an acute hospital setting until his death on 22nd 1 October because of the challenges of finding a suitable EMI placement for him.”
The response stated
“a GM Discharge Pathway and good Discharge to Assess (D2A) system in place”
Raised again
5 years 9 months later
“The inquest heard evidence that patients who suffer from severe dementia who need specialist placements often spend many months in hospital whilst funding and suitable placements are being found.”
Both reports highlight delays in discharging patients due to difficulties securing appropriate specialist placements. The earlier case concerns an EMI placement shortage, while the later case concerns funding and placement shortages for severe dementia patients.
University Hospitals Birmingham NHS Foundation Trust · NHS body
Insufficient patient observation leading to inpatient fallsEarlier report
“The central issue in this case relating to the fall on 11/06/24 was the lack of enhanced nursing observations.”
The response stated
“The Enhanced Care policy has been re-embedded into the ward and risks are discussed in the ward huddle following shift handovers.”
Raised again
1 year 6 months later
“Some, potentially all, of these falls occurred when Mr [name redacted] was not receiving the appropriate level of observation in accordance with his falls risk assessment and care plan.”
Both reports identify insufficient patient observation as a contributing factor to inpatient falls. The core concern is that patients at risk of falls are not receiving the level of monitoring required by their care plans.
Earlier report
“if an application had been submitted to the magistrates' court that day, it is unlikely that the warrant would have been executed before Mrs [name redacted] death. In evidence, I was informed by a number of mental health professionals that the time taken for a s135(2) warrant to be obtained from the magistrates' court and executed by the police was in the region of 2 weeks.”
The response stated
“The MPS will now request a weekly Community Consultation Meeting between AMHPs, MH policing teams, Neighbourhood policing teams, Crisis Teams, and Home Treatment Teams (HTT) to discuss those people who may be reaching the threshold for an assessment/S135 warrant application.”
Stated timescale: 17th November 2022
Raised again
1 year 2 months later
“A lack of awareness by the two less experienced officers about the process under section 135 MHA 1980, and a lack of inquiry by the more experienced officer as to the existence of such a warrant, together with a concern that it was not clear from the evidence where information about the warrant could be obtained by officers.”
Both reports highlight problems with the use of section 135 Mental Health Act warrants – the earlier report focuses on long delays in obtaining and executing such warrants, while the later report points to officers’ lack of awareness of the warrant process and where to find warrant information.
National Fire Chiefs Council · Local authority
Inadequate staff training for fire evacuation in specialist housingEarlier report
“The operator of the premises failed to ensure that staff on duty were competent to carry out a fire evacuation”
The response stated
“Face to face fire safety training is now provided to staff. This training is provided annually by Pinnacle and is delivered at each premises. The training covers, amongst other things, evacuation routes and procedures, fire drills and fire safety measures. A copy of the training handbook provided to staff as part of that training is attached.”
Stated timescale: annually
Raised again
4 years later
“Staff training is not standardised for ECSA (or sheltered accommodation more generally) and may not include, for example, evacuation strategy, emergency evacuation plans, the use of telecare/fire alarm system and fire suppression systems”
Both reports highlight deficiencies in staff training or competence for fire evacuation in specialist housing.
NHS England · National body
Unclear wording in NHS Pathways triage questionsEarlier report
“The pre-determined questions are the same whether the caller is an adult or a child. [name redacted] struggled to comprehend some of the medical terminology used during these calls.”
The response stated
“call handlers receive significant training in questioning and listening skills during initial core training and through ongoing training updates. This is supported and monitored through monthly call audit. This training and on-going monthly call audit are all mapped to the NHS Pathways Competencies.”
Raised again
6 years 11 months later
“Evidence showed that a key NHS Pathways question used during triage was not understood by the caller and did not elicit clinically significant information.”
Both reports highlight that the wording used in the NHS Pathways triage script can be unclear to callers, leading to misunderstandings. The earlier report focuses on confusing medical terminology for children, while the later report cites a specific question not understood by the caller.
Earlier report
“availability of ambulance crews is continuing to be compromised by delays at hospitals resulting in delays in response times which creates a risk to the life.”
The response stated
“The plan outlined key actions to recover and improve urgent and emergency care services, including: - improving ambulance response times; - increasing ambulance capacity through growing the workforce (for example, increasing clinical capacity in control rooms); - alongside broader system actions to improve flow through hospitals and reducing handover delays; - speeding up discharges from hospitals; - expanding new services in the community.”
Stated timescale: 2023/24
Raised again
2 years later
“Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought, reducing emergency response capacity during periods of high demand.”
Both reports identify ambulance handover delays at hospitals as reducing ambulance availability and increasing risk to life.
Earlier report
“This delay being significantly contributed to by the handover delays in hospitals.”
The response stated
“The NHS will focus on delivering the following range of practical actions to improve performance in 2025/26: - working towards delivering hospital handovers within 15 minutes, and implementing joint working arrangements that ensure that no handover takes longer than 45 minutes, - improving ambulance 'hear and treat' service rates, including increasing the proportion of Category 2 ambulance incidents where an ambulance clinician provides advice and treatment over the phone, - ensuring all 999 am”
Stated timescale: 2025-26
Raised again
1 year 2 months later
“Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought, reducing emergency response capacity during periods of high demand.”
Both reports identify prolonged ambulance handover times at hospitals as a factor that reduces ambulance availability for emergency calls.
Earlier report
“Continuing average handover delays (and therefore response delays) which create a risk of future deaths. The averages conceal spikes of delayed handover and ambulance response times which increase the risk of mortality.”
The response stated
“developing local partnership working between the NHS and social care and making sure people get the right support from health and social care services to return home as soon as possible”
Raised again
1 year 6 months later
“Ambulance handover delays affecting emergency availability Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought, reducing emergency response capacity during periods of high demand.”
Both reports identify prolonged ambulance handover times at hospitals as a factor that reduces emergency ambulance availability and increases mortality risk.
Earlier report
“Significant handover delays leading to ambulance resources being tied up at hospital with increased risk in mortality for patients in the community waiting for emergency ambulances.”
The response stated
“The NHS planning guidance also includes an implementation target for improving A&E waiting times compared to 2024/25, with a minimum of 78% of patients seen within 4 hours in March 2026 and increasing the proportion of patients admitted, discharged, and transferred from an emergency department within 12 hours across 2025/26 compared to 2024/25.”
Stated timescale: March 2026
Raised again
1 year later
“Ambulance handover delays affecting emergency availability Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought, reducing emergency response capacity during periods of high demand.”
Both reports identify ambulance handover delays at hospitals as a problem that ties up ambulance resources and reduces emergency availability.
Earlier report
“Significant handover delays at RCHT and other southwest hospitals leading to ambulance resources being tied up with increased response delays”
The response stated
“On 6 June 2025, we published our Urgent and Emergency Care Plan for 2025/26. The plan requires the NHS to focus on those activities that will have the biggest impact on improving urgent and emergency care performance, including ambulance response and handover times: - at least 78% of patients in A&E departments will be seen within 4 hours.”
Stated timescale: 6 June 2025
Raised again
11 months later
“Ambulance handover delays affecting emergency availability Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought”
Both reports identify ambulance handover delays at hospitals as a problem that ties up ambulance resources and reduces emergency availability. The later report describes the same hazard with slightly different wording but the same core issue.
Earlier report
“The Inquest heard that EMAS was unable to meet mean response standards at the time of the 999 call.”
The response stated
“the Health Secretary has ordered a full and independent investigation into NHS performance to provide a frank assessment of the issues and challenges it faces”
Raised again
1 year 9 months later
“Ambulance handover delays affecting emergency availability Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought,”
Both reports identify prolonged ambulance handover times at hospitals as a factor that reduces ambulance availability and increases risk of death.