“ are as follows – (1) UHCW acknowledged that Mr Watson’s discharge did not proceed…”
Dated 19 Aug 2016, from the coroner for Coventry. Sent to 3 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 14 Oct 2016. A reply may have been sent and not yet published.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.
- Report dated19 Aug 2016
- Deadline14 Oct 2016
- Published on judiciary.uk19 Aug 2016
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| University Hospitals Coventry and Warwickshire NHS Trust | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 14 Oct 2016. A reply may have been sent and not yet published. |
| University Hospital | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 14 Oct 2016. A reply may have been sent and not yet published. |
| Coventry | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 14 Oct 2016. A reply may have been sent and not yet published. |
The coroner’s concerns
are as follows – (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. (2) Issues around staffing allocation and resourcing were discussed in detail at the inquest. It remained unclear how, when additional resources were recognised as being required, these staff members were ‘labelled’ as being needed for a specific purpose. Futhermore, it was not clear what steps should be taken when the staff member does not attend, or is not available. (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. (4) Although UHCW provided oral evidence regarding some steps that have been taken to improve its investigatory processes, given the signficance of the issues that were raised, I believe it is necessary to ask the Trust to confirm these in writing and provide further 2 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. 6 ACTION COULD BE TAKEN In my opinion action could be taken to prevent future deaths and I believe that the addressee, has the power to take such action.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports
- Added to Minute Book
- 8 Oct 2026
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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