“The practicality, adequacy and reliability of hourly observations; (2) Evidence indicated…”
Dated 25 Apr 2017, from the coroner for Coventry. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Report put online after its 56 daysOrganisations 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; a reply may have been sent and not yet published.
judiciary.uk put this report online on 10 Jul 2017, after the 56 days for replies had ended (20 Jun 2017). These dates can’t tell us whether a reply was due before it went online. A reply may have been sent and not yet published.
- Report dated25 Apr 2017
- Deadline20 Jun 2017
- Published on judiciary.uk10 Jul 2017
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Coventry and Warwickshire Partnership NHS TrustNamed in the report as “Coventry & Warwickshire Partnership NHS Trust” | Report put online after its 56 daysNo response published on judiciary.uk. judiciary.uk put this report online on 10 Jul 2017, after the 56 days for replies had ended (20 Jun 2017). These dates can’t tell us whether a reply was due before it went online. |
The coroner’s concerns
(1) The practicality, adequacy and reliability of hourly observations; (2) Evidence indicated that in consequence of lighting, distance and obstructions it was not practical to reliably assess, through the door window, whether a patient was breathing; (3) The recording of the patient's position in bed was not accurately recorded on the observation chart. At least one entry was, having regard to the evidence, obviously erroneous; (4) Potential areas of concern, in relation to the completion of the observation chart, were not detected on the night; (5) There was a reluctance by members of staff to enter a patient's room to conduct observations; (6) The extant Trust policy, in relation to observations, lacks the necessary clarity, direction and succinctness that can readily be understood and applied by the members of staff who undertake the observations on the ward. !2
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, 2017-0136
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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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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