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
“During the inquest evidence was given that ambulance availability is being jeopardised by crews being delayed at hospital when handing patients over to Accident and Emergency staff.”
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
10 years 9 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 ambulance handover delays at hospitals as a factor that reduces emergency ambulance availability.
Earlier report
“Continuing average handover delays (and therefore response delays) which create a risk of future deaths.”
The response stated
“maintaining capacity gains in acute hospital beds and ambulance hours on the road achieved in 2023-24”
Stated timescale: 2023-24
Raised again
1 year 5 months later
“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 as a factor that reduces emergency availability and increases mortality risk. The earlier report links delays to systemic discharge and bed shortages, while the later report notes prolonged handover times directly causing unavailable ambulances.
Earlier report
“Significant handover delays leading to ambulance resources being tied up at hospital”
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
11 months later
“Ambulance handover delays affecting emergency availability”
Both reports identify ambulance handover delays as a problem that ties up ambulance resources and reduces emergency availability. The later report describes the same hazard with a focus on its impact during high demand.
Earlier report
“Significant handover delays at RCHT and other southwest hospitals leading to ambulance resources being tied up with increased response delays and increased mortality risks for patients in the community waiting for emergency ambulances.”
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
10 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 ambulance handover delays as a cause of reduced emergency availability and increased risk. The later report describes the same mechanism—prolonged handover times limiting ambulance resources—though in a different geographic area.
Earlier report
“I am concerned that these continuing delays for ambulances at hospital handovers reflects a risk of deaths into the future.”
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 8 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 ambulance handover delays at hospitals as a factor that reduces emergency availability and poses a risk of future deaths.
Earlier report
“The delay in an ambulance attending patients due to the unavailability of ambulances. 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 1 month 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 ambulance availability for emergency calls. They describe the same causal chain: handover delays → ambulances stuck on premises → inability to respond to new emergencies.
East Suffolk and North Essex NHS Foundation Trust · NHS body
Junior staff reluctance to challenge senior cliniciansEarlier report
“The nurse did not feel confident enough to challenge the prescription (as she perceived it) effectively or escalate / refer to another doctor.”
The response stated
“We have reviewed and updated the ESNEFT Morphine Administration Guideline and the Naloxone Administration Guideline in line with those set out in the British National Formulary (BNF).”
Raised again
5 years 5 months later
“The junior doctor did not feel able to challenge the view of the Consultant to discharge nor did they seek to reapproach them with fuller information.”
Same coroner as the earlier report.
Both reports highlight a lack of confidence among junior staff to question senior clinicians about clinical decisions.
NHS England · National body
Lack of mandatory ACCT training for agency staffEarlier report
“The training of agency staff in ACCT does not appear to be part of the commissioning process by NHS England and individual providers do not appear to provide training to agency staff in the ACCT process.”
The response stated
“NHS England is the responsible organisation for the commissioning of healthcare into prisons, which is devolved to regional teams. Commissioning healthcare in prisons is done on a principle of equivalence, which has been defined by the Royal College of General Practitioners (RCGP) and has been adopted by the National Prison Partnership Board1. The definition broadly states the aim is to ensure people detained in prisons in England, are offered provision of and access to appropriate services and”
Raised again
2 years 5 months later
“(2) There are no mandatory procedures to ensure that, before they are deployed in the prison setting, Oxleas agency staff have the same mandatory ACCT training as that provided to permanent healthcare staff.”
Both reports highlight the absence of mandatory ACCT training for agency healthcare staff working in prisons. They describe the same gap in ensuring agency staff receive the same training as permanent staff.
National Institute for Health and Care Excellence · National body
Inadequate shift handover communication leading to missed critical patient detailsEarlier report
“both key support workers who knew Mr [name redacted] best failed to carry out the 30 minute observations during the morning and afternoon shifts”
The response stated
“The guideline is currently undergoing a surveillance review exercise to determine whether It should be updated As a result of your report, the review Is likely to conclude that an update is required so that it is clearer that the guideline applies to indirect head injury (for example, by making the definition more accessible to users) A final surveillance review decision Is due to be published in September 2019”
Stated timescale: September 2019
Raised again
6 years 8 months later
“pertinent general information about [name redacted] was missing from that handover sheet”
Both reports highlight failures in communicating essential patient information during handovers, leading to missed critical details. The earlier case concerns verbal shift handover meetings omitting observation requirements; the later case concerns incomplete written handover sheets for agency workers.
Department of Health and Social Care · National body
Delayed discharge increases infection risk for frail elderly patientsEarlier report
“The evidence before the inquest was that delayed discharges such as Mr [name redacted] put the lives of frail elderly patients at risk as it is far more likely that they will become deconditioned and develop and infection if they spend unnecessary time in hospital.”
Raised again
2 years 7 months later
“patients are kept in hospital for longer and thus are more at risk of contracting hospital acquired illness”
Both reports identify delayed hospital discharge as increasing patients' risk of acquiring infections or illness while awaiting appropriate community care.
Royal Cornwall Hospital · NHS body
Lack of standard operating procedures for worsening patients in renal unitEarlier report
“There were no applicable standard operating procedures for worsening patients in the renal unit at the date of [the deceased]'s death and none had been implemented by the date of Inquest.”
The response stated
“Standard Operating Procedure (SOP): This (SOP) is now completed and has been uploaded onto the Trust's intranet page for all staff to have access to. A copy of the SOP is attached to the response as 'Enclosure”
Raised again
7 months later
“There was insufficient evidence before the court to indicate that the above failings found at Inquest had been addressed by the hospital.”
Same coroner as the earlier report.
Both reports concern the lack of proper standard operating procedures for managing worsening patients in the renal unit. The later report notes that there is insufficient evidence those procedural shortcomings have been resolved.
His Majesty's Prison and Probation Service · National body
Lack of basic first aid training and CPR among prison officersEarlier report
“(1) Some Prison staff had not received any cardiopulmonary resuscitation training. Either as part of initial training or any refresher training.”
The response stated
“The Governor at HMP New Hall has reviewed the band/grade and number of staff who need to be trained in first aid, and the number of such staff required on duty at times throughout the day. The prison currently has 40 staff trained in FAW and 48 in EFAW, and these numbers are considered to be sufficient to ensure that an appropriate response can be provided in any emergency situation that may arise at any time.”
Raised again
7 years 4 months later
“no refresher CPR training had been provided to prison staff since 2023”
Both reports highlight that prison staff lack refresher cardiopulmonary resuscitation training, which impairs their ability to respond to emergencies.