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
“Mrs. KENNEDY was transferred from AMU in a chair, not a trolley. (3) Handover was incomplete and unhelpful. | (4) She arrived unkempt”
The response stated
“The Trust introduced a new clinical management structure last autumn, a very few weeks before Mrs [name redacted] last admission. The clinical team now managing the acute medical unit have worked tirelessly to introduce a range of changes in order to improve the functioning and quality of the Acute Medical Unit. These incorporate a range of actions relating to the workforce, education, environment, equipment, patient flow, teamwork and communications.”
Stated timescale: last autumn
Raised again
1 year 11 months later
“handover relies more and more on the notes and the notes are relying more and more on tick boxes which are simply not adequate to deal with the individualities of each patient.”
Same coroner as the earlier report.
Both reports identify problems with patient handover processes. The earlier report describes handover as incomplete and unhelpful, while the later report criticises handover for relying on inadequate tick‑box notes that fail to capture individual patient needs.
Network Rail · National body
Public access to live rail at platform endEarlier report
“Recommendations in The BTP Post Fatality Report to create a safer environment at the bridge and restrict public access to the railway had not been effected by the time of the inquest.”
The response stated
“We are in the process of installing acoustic fencing on both sides of the track at a height of 3m. This will also have anti-climb wire extensions fitted as an additional deterrent at certain sections.”
Raised again
1 year 2 months later
“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.”
Both reports highlight inadequate physical barriers that allow public access to the railway, creating a risk of trespass. The earlier report notes unimplemented recommendations to restrict access, while the later report observes existing fences and walls in disrepair.
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 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
8 months later
“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.”
Both reports highlight insufficient physical barriers that allow unwanted access to the railway line. The earlier case concerns a weak wooden gate, while the later case notes broken or missing fencing and walls.
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. Both the gate and | fence provide little deterrence or hindrance to someone wanting to gain | access to the railway”
The response stated
“e We have commissioned works to enhance the fencing and gates in this area. These works will be delivered by 15”
Stated timescale: 15
Raised again
8 months later
“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.”
Both reports highlight inadequate fencing or barriers that fail to deter access to the railway line. The earlier report cites a gate and fence offering little hindrance, while the later report notes broken, missing, or disrepaired fencing and walls.
Earlier report
“The lack of a process for following up non- attendance at the Reception Healthcare first night screening”
The response stated
“The process now is that a Second Health Screen is undertaken within 72 hours of an inmate arriving at HMP Chelmsford and at that second health screen there would be a Care UK Cltrncal SeMces llm,ted - Registered ,n England No 3462881 Registered Office Connaught House.”
Stated timescale: within 72 hours
Raised again
7 months later
“There was no second reception screen conducted. If Mr [name redacted] was not brought to healthcare staff for his second reception screen then healthcare staff needed to follow this up.”
Both reports highlight the absence of a reliable process to ensure that a second reception health screen occurs and that any missed attendance is followed up. They describe the same gap in follow‑up procedures for healthcare screening.
NHS England · National body
Lack of basic first aid training and CPR training and defibrillator use by Prison Officers and StaffEarlier 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 later
“The prison officers did not have even the most basic first aid and cardiopulmonary resuscitation (CPR) training.”
Both reports highlight that prison officers lack basic first aid and CPR training, putting prisoners at risk during medical emergencies. The later report reiterates the same gap despite noting some training efforts.
Earlier report
“There is no record from that meeting or any other time, of any consideration of or management plan for Mr [name redacted] depression.”
The response stated
“in early May 2016, when the refresher training for 2016/17 for staff in EOC began, a session was included that made specific reference to HMP Pentonville and of the requirement that when a call from HMP Pentonville was received, at the start of the call the emergency medical dispatcher was to seek confirmation of the gate the LAS should attend. This training is in process and due to be completed in November 2016.”
Stated timescale: November 2016
Raised again
7 months later
“The second reception (well man) screening nurse did not explore the history of depression recorded”
Same coroner as the earlier report.
Both reports highlight failures to properly identify or act on a prisoner's depression history.
The Priory Group · Company or provider
Inadequate nighttime patient observation documentationEarlier report
“There were repeated failures to perform basic nursing observations”
The response stated
“In response to points one and three, | understand that the records falsification and a number of key missing observations in Mr [name redacted] case for the afternoon he absconded from the ward, fell to one nurse, | am informed that the relevant individual was disciplined through Priory's internal processes and dismissed from employment. She was also referred to the NMC as her actions fell short of the standard required.”
Raised again
2 years 8 months later
“The system of observations carried out within the unit, particularly at night is in need of reform.”
Both reports highlight failures in performing proper patient observations, especially regarding timing and documentation.
His Majesty's Prison and Probation Service · National body
Risk of suicide and self-harm in newly arrived prisonersEarlier report
“staff had failed to identify or properly assess the risk of suicide and self harm in newly arrived prisoners.”
The response stated
“From January 2016, CNWL has increased the number of experienced Mental Health trained nursing staff into the First Night Centre.”
Stated timescale: January 2016
Raised again
10 months later
“Admission staff must raise an ACCT Plan when a prisoner is identified at risk of suicide or self harm”
Both reports concern the identification and response to suicide/self‑harm risk at prisoner reception.
Betsi Cadwaladr University Health Board · NHS body
Ambulance delays leading to resource unavailabilityEarlier report
“the current practices in place for the handover of patients at an Emergency Department far too often results in 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
“incidents. WAST will review the Welsh MPDS codes and accompanying response recommendations (known as the 'DCR' table), with the intention of broadening the current response categories listed above to further distinguish between higher and lower acuity calls”
Raised again
2 years 7 months later
“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”
Same coroner as the earlier report.
Both reports describe unacceptable delays where patients wait in ambulances because emergency department handover or flow processes are inadequate, tying up ambulance resources. The later report notes that the problem persists despite earlier changes.
Brighton and Sussex University Hospitals NHS Trust · NHS body
Incomplete national early warning system scoringEarlier report
“after a NEWS score of 8, and a medical emergency team call made at about 09:45 on the morning of the 23 February 2015, the scoring is not completed”
The response stated
“We have carried out a careful review of the medical records with the appropriate personnel.”
Stated timescale: 7 November 2015
Raised again
1 year later
“there were missed opportunities to escalate Mrs [name redacted] treatment arising from raised NEWS scores where there was no report of those raised scores either to the doctors on the ward or to the critical care outreach team”
Same coroner as the earlier report.
Both reports highlight failures to act on abnormal National Early Warning Scores (NEWS) that should trigger escalation of care. The earlier case notes missing completion of scoring after a high score; the later case notes unreported raised scores that did not prompt calls to clinicians.
Avon and Wiltshire Mental Health Partnership NHS Trust · NHS body
Lack of inpatient mental health bedsEarlier report
“no beds would have been available at Green Lane Hospital Devizes when an enquiry was made on 6 July 2014”
The response stated
“The Trust Board closely monitors bed pressures and out of area placements and is continually working with its Commissioners and NHS England to manage the situation optimally.”
Raised again
1 year 4 months later
“provision of in-patient beds is subject fo the funding provided by the Bristol Clinical Commissioning Group (CCG).”
Both reports highlight that insufficient inpatient mental‑health bed capacity prevented timely admission or assessment of patients expressing suicidal intent. The core issue is the unavailability of beds when clinical need arises.