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
Earlier report
“The evidence was that this layout could mislead road users (pedestrians and motorists) into believing that this is a standard dual carriageway. Ordinary traffic has been seen in the dedicated busway, and pedestrians could be misled into looking the wrong way”
The response stated
“A zebra crossing was installed on 15 March 2016, south of, but close to, the junction, to provide an additional crossing from the Millennium Village area to the existing primary school, and a safer crossing route between Pilot Busway and West Parkside.”
Stated timescale: 15 March 2016
Raised again
1 year 3 months later
“(1) No road markings indicating the direction pedestrians should look when crossing”
Both reports highlight that the road layout can cause pedestrians to look in the wrong direction when crossing, creating a safety risk. The earlier report cites the unusual side‑by‑side busway/road layout as misleading, while the later report notes the absence of road markings indicating the correct looking direction.
Pennine Acute Hospitals NHS Trust · NHS body
Incomplete and inaccurate nursing records and documentationEarlier report
“During the course of the inquest hearing it became apparent that the nursing tools (in particular, the 'Purpose T'), assessments, records, associated documentation and nursing discharge summary were incomplete and/or inaccurate.”
The response stated
“We are undertaking a review of current documentation to ensure it meets all Trust standards and therefore supports improvements in care delivery. On a monthly basis the ward is audited using the nursing metrics which includes the quality of record keeping.”
Stated timescale: July 2015
Raised again
2 years 4 months later
“Gaps within the documentation/record keeping/missing entries by both doctors and nurses (including fluid balance charts for a patient in heart failure and subject to fluid restriction, risk assessments, care planning, rounding tool and medical attendance upon the deceased).”
Same coroner as the earlier report.
Both reports identify deficiencies in clinical documentation and record‑keeping practices across multiple tools and forms.
Earlier report
“When a referral was made this was made to Healthy Minds. The Court heard evidence how this was not a case which was suitable for Healthy Minds as it was complex and involved potentially complex PTSD.”
The response stated
“The CCG will clarify the Individual Funding Request process to ensure that, where required, Pennine Care staff can apply for individual funding for extraordinary care, e.g. for Complex PTSD and ensure that PC.FT staff are fully briefed about the process by 1/6/17.”
Stated timescale: 1/6/17
Raised again
9 months later
“Similarly, patients cannot access a qualified Psychologist whilst under the care of the Home Treatment Team (HTT') etc. The only way for patients to get access to a Psychologist is through referral to 'Healthy Minds'. Health Minds cannot provide access where the patient remains under the care of the HTT etc.”
Both reports highlight that patients cannot obtain appropriate psychological support through Healthy Minds while under other care pathways. The earlier case concerned an unsuitable referral for complex PTSD; the later case notes a general lack of psychologist access for Home Treatment Team patients.
Earlier report
“The doctor did not ask Ms [name redacted] about thoughts of suicide within the context of her earlier declaration that she would die that night.”
The response stated
“Development of care Guidelines to be a a) June 2015-On_ | The set of guidelines and agreement guidelines relating to signed off at August track. The police patients brought into the 2015 ED Board and | Consultant in guidelines have _| (draft v3 attached)”
Stated timescale: 01/08/15
Raised again
2 years 6 months later
“There seemed a lack of understanding by the staff of the difference between a patient answering positively that they have no suicide plan and a patient simply refusing to answer a question about a suicide plan.”
Same coroner as the earlier report.
Both reports highlight shortcomings in assessing suicide risk during mental health encounters.
His Majesty's Prison and Probation Service · National body
Risk of suicide and self-harm in newly arrived prisonersEarlier report
“Admission staff must raise an ACCT Plan when a prisoner is identified at risk of suicide or self harm”
The response stated
“NOMS acknowledges the potential for confusion regarding the opening of an ACCT, and this will be resolved in the revision of PSI 64/2011 due for completion by the endjof April 2017.”
Stated timescale: endjof April 2017
Raised again
11 months later
“He was not on an ACCT but perhaps should have been given his threats of suicide and self-harm articulated by him in a letter to a Governor on an adjudication the day before his death.”
Same coroner as the earlier report.
Both reports concern the identification of suicide or self‑harm risk and the need to place a prisoner on an ACCT plan. The earlier report focuses on admission staff duties, while the later report highlights missed opportunities to act on expressed threats.
Camden and Islington NHS Foundation Trust · NHS body
Delayed mental health assessment in emergency unitEarlier report
“Most importantly, [name redacted] waited four hours in the emergency unit before he saw a mental healthcare professional for the first time.”
The response stated
“We have strengthened the direct mental health referral protocol from Whittington Emergency Department (ED) triage to the Camden and Islington Mental Health Liaison Team Service, so that patients attending Whittington Emergency who need to see a mental health professional can be immediately and directly referred. This mental health referral protocol was in place before your inquest into Mr [name redacted] death, but has since been significantly strengthened in that the patient themselves can now trigger”
Raised again
1 year 9 months later
“Mr [name redacted] waited in the emergency unit for 40 hours and so it was unsurprising that he was then keen to go home.”
Same coroner as the earlier report.
Both reports describe long waits in the emergency unit leading to delayed mental health assessment and risk of premature discharge.
Camden and Islington NHS Foundation Trust · NHS body
Lack of timely crisis team visits and communicationEarlier report
“- to visit Mr [name redacted] twice a day, despite a plan so to do;”
The response stated
“Following the inquest into the death of Mr [name redacted] you noted the following failures by the Crisis team: to visit Mr [name redacted] twice a day despite a plan to do so; to record why twice daily visits were not attempted; to communicate within the team and with the two Crisis houses; to consider hospital admission despite the fact that Mr [name redacted] was known to have made several suicide attempts; had told staff he did not feel safe at home; was observed to be keeping a rope at home; told staff he would kill”
Raised again
2 years 3 months later
“The mental health nurse assessed Mr [name redacted] as rational and having good insight, despite the fact that Mr [name redacted] once again (as he had done repeatedly for many months) raised a physical problem for which no organic cause had been found.”
Same coroner as the earlier report.
Both reports highlight failures to properly assess and respond to patients expressing suicidal intent, leading to inadequate care and premature discharge.
His Majesty's Prison and Probation Service · National body
Missing escort records during reception screeningEarlier report
“The person escort record (PER) and appended report of the forensic medical examiner (FME) that accompanied Mr [name redacted] to HMP Pentonville did not accompany him to nurse reception screening.”
The response stated
“The change that has been implemented is a control question in the first reception screen which is a mandatory field so the nurse needs to stop and answer the question. It asks if the nurse has seen the PER. All nursing staff have been instructed and are aware that they are not to screen any prisoner without a CSRA and PER as minimum requirement to aid screening.”
Stated timescale: early December 2016
Raised again
7 months later
“During the course of the inquest into the death of [name redacted] (Ned) O'Donnell it was apparent that a nurse carrying out the first health reception screening was not given access to the PER (Prisoner Escort Report) which had accompanied the prisoner from another prison establishment.”
Both reports describe that nurses performing initial health reception screening did not receive the Prisoner Escort Report (PER) accompanying the prisoner.
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 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
10 months later
“The issues of admission to the Emergency Department/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by the Senior Coroner on several occasions following previous inquests”
Both reports highlight ongoing patient flow problems in the Emergency Department that cause delays and put patients at risk. The earlier report focuses on ambulance back‑up due to ED delays, while the later report stresses continued admission/resource availability issues despite prior warnings.
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”
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
9 months later
“The issues of ambulance delays/admission to ED/availability of resources/patient flow”
Same coroner as the earlier report.
Both reports highlight ongoing delays in patient flow causing ambulance backlogs and emergency department congestion. The later report reiterates the same specific hazard of ambulance delays and resource availability despite prior warnings.
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 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
9 months later
“unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”
Same coroner as the earlier report.
Both reports highlight unacceptable delays where patients wait in ambulances because emergency department flow problems make ambulance resources unavailable for other calls.
Department of Health and Social Care · National body
Lack of electronic access to primary care medical notesEarlier report
“neither they nor the hospital Emergency Departments, have direct access to GP [name redacted]”
The response stated
“Stockport CCG is already enagaged in continual improvement work in this area. However, as a result of this investigation, the CCG is also planning the following measures: © to seek formal assurance from Mastercall about processes for new starters and contingency plans for when practitioners do not have Smartcards”
Raised again
3 years 1 month later
“lack of access to GP information regarding Mr [name redacted] diagnosis of haemophilia, could have caused or contributed to his death”
Both reports highlight the inability of healthcare staff to access patients' GP records, which could lead to avoidable harm.