Recipient

University Hospital Coventry

First report 19 Aug 2016•Latest report 19 Aug 2016

Recipient record

Reports, concerns and published responses

Health and care · Healthcare site. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from University Hospital Coventry linked to the concerns in each report. Select any concern, action or position to view the source wording.

19 Aug2016
Coventry
Concerns raised6
1. Failure to monitor and assess staff working permanent night shifts
2. Failure to designate additional staff resources for a specific purpose
3. Failure to cooperate with police investigations
1. Failure to derive wider organisational learning from investigations
2. Failure to have steps for responding when required staff are absent or unavailable
3. Failure to ensure patients are discharged with appropriate medication
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

George Watson · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

George Watson fell from his bed at approximately 04:30 on 3 September 2014 after being admitted following a fall, and died on 21 October 2014 from a subdural haemorrhage, skull fracture and compound fracture of his left humerus. The principal concerns included supervision and staffing arrangements, raised bed rails, discharge without necessary oral pain relief and inadequate investigatory processes, including cooperation with police inquiries.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospital Coventry; that does not assign responsibility.
PFD Monitor interpretation
Failure to monitor and assess staff working permanent night shifts
Wider context from the report
“(3) The ability of UHCW to monitor and assess staff who work on permanent night shifts was raised at the inquest. Evidence was adduced that this issue is being considered at present but it was unclear whether steps have been, or will be taken to address this issue. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospital Coventry; that does not assign responsibility.
PFD Monitor interpretation
Failure to designate additional staff resources for a specific purpose
Wider context from the report
“(2) Issues around staffing allocation and resourcing were discussed in detail at the inquest. It remained unclear how, when additional resources recognised as being required, these staff members were ‘labelled’ as being needed for a specific purpose. Furthermore, it was not clear what steps should be taken when the staff member does not attend, or is not available. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospital Coventry; that does not assign responsibility.
PFD Monitor interpretation
Failure to cooperate with police investigations
Wider context from the report
“(4) Although UHCW provided oral evidence regarding some steps that have been taken to improve its investigatory processes, given the significance of the issues that were raised, I believe it is necessary to ask the Trust to confirm these in writing and provide further evidence that it has addressed the issues that arose in the investigation of this case. In particular, the need to cooperate with police investigations was noted to be a learning point for one witness but wider learning for the Trust as a whole was not adduced in evidence. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospital Coventry; that does not assign responsibility.
PFD Monitor interpretation
Failure to derive wider organisational learning from investigations
Wider context from the report
“(4) Although UHCW provided oral evidence regarding some steps that have been taken to improve its investigatory processes, given the significance of the issues that were raised, I believe it is necessary to ask the Trust to confirm these in writing and provide further evidence that it has addressed the issues that arose in the investigation of this case. In particular, the need to cooperate with police investigations was noted to be a learning point for one witness but wider learning for the Trust as a whole was not adduced in evidence. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospital Coventry; that does not assign responsibility.
PFD Monitor interpretation
Failure to have steps for responding when required staff are absent or unavailable
Wider context from the report
“(2) Issues around staffing allocation and resourcing were discussed in detail at the inquest. It remained unclear how, when additional resources recognised as being required, these staff members were ‘labelled’ as being needed for a specific purpose. Furthermore, it was not clear what steps should be taken when the staff member does not attend, or is not available. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospital Coventry; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure patients are discharged with appropriate medication
Wider context from the report
“(1) UHCW acknowledged that Mr Watson’s discharge did not proceed satisfactorily. However, no evidence was provided as to what steps have been taken to address this issue. In particular, it is not clear whether the risk that patients are discharged without appropriate medication has been addressed. ”
Open source report

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised6

Failure to monitor and assess staff working permanent night shifts

Failure to designate additional staff resources for a specific purpose

Failure to cooperate with police investigations

Failure to derive wider organisational learning from investigations

Failure to have steps for responding when required staff are absent or unavailable

Failure to ensure patients are discharged with appropriate medication