University Hospital Coventry

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First report 19 Aug 2016•Latest report 19 Aug 2016

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

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.

  1. Coventry

    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
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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