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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Welsh Ambulance Service NHS Trust · Ambulance service
Patient flow problems leading to ambulance handover delaysEarlier report
“substantial delays in the handover of patients particularly as a result of problems in 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. The changes made clearly identify those patients who require an immediate life-saving response and these patients receive the highest priority response in the fastest possible time. foe) All other patients receive a bespoke”
Stated timescale: October 2015
Raised again
1 year 1 month later
“patient flow and the multifactorial problems associated with cases of this nature have been reported upon by this Court on several occasions”
Both reports highlight ongoing patient‑flow problems that cause ambulance handover delays and hinder timely admission.
Welsh Ambulance Service NHS Trust · Ambulance service
Ambulance handover delays due to bed shortagesEarlier 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
1 year 9 months later
“The issues of ambulance delays/admission to ED/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by this Court on several occasions”
Both reports highlight prolonged ambulance delays due to poor patient flow and limited resource availability, which keep ambulances tied up and endanger patients.
Medicines and Healthcare products Regulatory Agency · National body
Missing fire hazard warnings on emollient cream packagingEarlier report
“(2) Warnings of such risks are not displayed on all product packaging.”
The response stated
“PAGB and its member companies recognise that clear information needs to be made available to warn of the risk of increased flammability of clothing and bedding which has been in contact with paraffin-containing emollients.”
Stated timescale: 30 September 2017
Raised again
10 months later
“e Warnings of such risks are not displayed on all product packaging”
Both reports highlight that warnings about the fire‑hazard risk of paraffin‑containing emollient creams are missing from product packaging. They refer to the same specific hazard and the same mechanism of risk.
North East Ambulance Service NHS Foundation Trust · Ambulance service
Ambulance arrival delay due to operational shortagesEarlier report
“the reasons for the delay of the ambulance arrival include severe demand and shortages in the division.”
The response stated
“the Trust has undertaken initiatives to seek to educate both the public in relation to the appropriateness of making calls and to work with colleagues in other sectors to try to reduce the demand on Trust services.”
Raised again
1 year 11 months later
“although there were several other initiatives under way, operational shortages were ongoing.”
Both reports highlight ongoing operational shortages and insufficient resources relative to demand as a cause of delayed ambulance responses.
North East Ambulance Service NHS Foundation Trust · Ambulance service
Paramedic staffing shortages impacting ambulance response timesEarlier report
“During the inquest evidence was given that there is a national shortage of paramedics, which is particularly acute in the North East”
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
2 years 8 months later
“I was told there were still 32 paramedic vacancies to be filled a year on after [the deceased]'s death.”
Both reports highlight ongoing problems with paramedic staffing levels affecting ambulance response times. The earlier report notes a national shortage especially in the North East, while the later report cites 32 unfilled paramedic vacancies a year after a death.
Earlier report
“concern was raised by the family with regard to the length of time taken before Mr [name redacted] could be declared missing and the police informed.”
The response stated
“we have since revised the documents clinicians are asked to complete. This is to ensure they are less repetitive and better support succinct recording of relevant issues. Regular audits are completed to ensure adequate standards are met.”
Raised again
4 years 5 months later
“Need for clear information to be given by hospital staff when making the 999 call to report a patient has gone AWOL”
Both reports highlight shortcomings in the hospital's AWOL reporting process that delay police notification. The earlier report cites a delay in declaring a patient missing; the later report stresses the need for clear information during the 999 call to enable swift police action.
Network Rail · National body
Public access to live rail at platform endEarlier report
“The British Transport investigation revealed that the deceased gained | access to the railway line through an access gate at Lower Farm Road, Bromham, Bedfordshire. The gate is of wooden construction and | provides little deterrence or hindrance to someone wanting to gain access to the railway”
The response stated
“In relation to the wooden gate, this gate will be upgraded by the 2° December 2016, as part of a comprehensive upgrade to the fencing at this site.”
Stated timescale: 2 December 2016
Raised again
1 year 5 months later
“British Transport Police investigating revealed that fencing beside the railway track was inadequate especially at the rear of a scrap metal dealer located off St Albans Road and Bedford Street, ieading toa risk that adults and children may trespass on the line where the speed limit is 100mph.”
Both reports highlight insufficient barriers (a wooden gate and trackside fencing) that fail to deter trespass onto the railway. The core issue is inadequate fencing/gate allowing access, though the locations and specific barrier types differ.
Network Rail · National body
Public access to live rail at platform endEarlier report
“Photographs of the location where the death occurred, provided by British Transport Police show that various sections of fencing and walls separating the public footpath from the railway line were broken, missing or in disrepair.”
The response stated
“Network Rail has reviewed the active fencing proposals for upgrade on both sides of the track in the section where the incident occurred and have included these in our 2018 renewals plan”
Stated timescale: 2018 renewals plan
Raised again
8 months later
“fencing beside the railway track was inadequate especially at the rear of a scrap metal dealer located off St Albans Road and Bedford Street”
Both reports point to inadequate fencing or barriers alongside the railway line that could allow trespass. They differ in the specific locations and contexts described.
His Majesty's Prison and Probation Service · National body
Lack of basic first aid training and CPR among prison officersEarlier report
“Action is required to ensure that Prison Officers and Staff with direct access to prisoners have basic first aid training, CPR training and familiarisation with the use of a defibrillator.”
The response stated
“all but two of the CMs at the prison have been trained, and those two members of staff will be provided with training as soon as they return to duty. HMP Coldingley also uses a monthly closedown of the prisoner regime to provide opportunities for training for the wider staff group and this includes instruction on CPR and on the use of defibrillators.”
Stated timescale: as soon as they return to duty
Raised again
2 years 9 months later
“(4) There is no mandatory first aid training for existing (as opposed to new) prison officers.”
Both reports highlight the absence of required first‑aid training for prison staff who work directly with prisoners.
Earlier report
“There was a clear breakdown in sharing of information known to the mental health team with other members of some ACCT reviews.”
The response stated
“an amended arrangement has been put in place to facilitate the presence of a member of the mental health team at ACCT reviews that take place at the weekend”
Raised again
3 years later
“Although, , Head of Healthcare, described how healthcare staff have received recent encouragement to make entries on a prisoner's ACCT in relation to matters that could bear on risk, 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 and the infrequent occasions that Care UK staff made entries on Mr [name redacted] ACCT daily record.”
Both reports highlight failures in sharing relevant information during ACCT reviews, specifically concerning mental health input and record entries.
NHS England · National body
Unclear hospital transfer process and formsEarlier report
“The lack of clarity regarding the hospital transfer process. The evidence at the inquest demonstrated that this is currently shrouded in confusion and contradiction”
The response stated
“The following information describes the commissioning arrangements for healthcare for someone being held in police custody.”
Raised again
10 months later
“In this case there was confusion as to whether on an in-patient transfer there should be a Form 2 to go alongside the Form 1 procedure.”
Both reports highlight uncertainty and lack of clear documentation around the transfer of patients between settings.
Earlier report
“The Court heard evidence that the referral document completed by the GP was not particularly detailed and therefore the complexity of the case was not apparent and the case was accepted.”
The response stated
“The CCG will work with PCFT and GPs to review and establish clear pathways into MH support for people with complex needs. This will identify any gaps which will be taken forward within commissioning intentions. We have commenced this work already and aim to conclude it within four months.”
Stated timescale: four months
Raised again
9 months later
“The form completed by the 136 suite team was sent to the GP with the box refer to GP ticked. After receipt by the GP practice there was an assumption that any necessary referral had already been made and no referral was discussed or made.”
Both reports highlight failures in the transfer of referral information between general practitioners and mental health services, leading to missed follow‑up care.