Central to the workings of a hospital are the technical and bureaucratic systems that ensure the effective coordination of information and biological materials of patients across time and space. In this paper, which is based on ethnographic research in a public referral hospital in Freetown, Sierra Leone, conducted between October 2018 and September 2019, we adopt a patient pathway approach to examine moments of breakdown and repair in the coordination of patient care. The authors show how coordination work depends on frequent small acts of intervention and improvisation by multiple people across the pathway, arguing that such interventions depend on the individualisation of responsibility for ‘making the system work’ and are best conceptualised as acts of temporary repair and care for the health system itself.