Sunderland Royal Hospital

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First report 10 Dec 2021•Latest report 10 Dec 2021

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 Sunderland Royal Hospital linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Newcastle upon Tyne

    AI-generated summary

    Edward Cockburn · 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

    Edward Cockburn died after falling from an upper-storey window in a sluice room at Sunderland Royal Hospital on 15 March 2020, suffering injuries from which he later died. The report identified failures in enhanced-care assessments and observations, an unsecured sluice-room door, a failed window restrictor fixing, and significantly substandard staffing. It also raised concerns about staff training and the communication of updated window-restrictor fitting guidance.

    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 Sunderland Royal Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of a procedure to record and audit SafeCare training delivery and efficacy

    Wider context from the report

    “Staff appeared to be unaware of the Trusts Standard Operating Procedure in relation to Enhanced Care/Observation. Training at that time had not been given to relevant members of staff in connection with the SafeCare system. Whilst training and information had been cascaded there was no procedure in place in relation to any training that could record and thereafter audit the efficacy of that system with particular regard to when the training was delivered and by whom and to whom it was delivered. ”
    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 Sunderland Royal Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide SafeCare system training to relevant staff

    Wider context from the report

    “Staff appeared to be unaware of the Trusts Standard Operating Procedure in relation to Enhanced Care/Observation. Training at that time had not been given to relevant members of staff in connection with the SafeCare system. Whilst training and information had been cascaded there was no procedure in place in relation to any training that could record and thereafter audit the efficacy of that system with particular regard to when the training was delivered and by whom and to whom it was delivered. ”
    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 Sunderland Royal Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure staff awareness of the Standard Operating Procedure for Enhanced Care/Observation

    Wider context from the report

    “Staff appeared to be unaware of the Trusts Standard Operating Procedure in relation to Enhanced Care/Observation. Training at that time had not been given to relevant members of staff in connection with the SafeCare system. Whilst training and information had been cascaded there was no procedure in place in relation to any training that could record and thereafter audit the efficacy of that system with particular regard to when the training was delivered and by whom and to whom it was delivered. ”
    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 Sunderland Royal Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Unsafe positioning of window restrictor fixings on pivot-window sills

    Wider context from the report

    “The fixing was attached to the sill of the window in accordance with fitting instructions issued by Jacklok and dated July 2017. Subsequent to the installation a data sheet was issued indicating that the fixing should be attached to the window frame only. This change in data/guidance was not highlighted to South Tyneside and Sunderland NHs Trust and presumably other hospital trusts. The position of the fixing on the sill enabled the restrictor to be more readily defeated bearing in mind this was a pivot window Jacklok have been requested to take action as follows (a) To ensure that the guidance is changed clarify the necessity to attach the fixing to the frame and proximity to the points of pivot (b) To ensure that this is effectively communicated to and highlighted with all NHS Trusts and other relevant users using the Jackloc window restrictor system The relevant Department guidance is Health Building Note 00-10Part D Windows and Associated Hardware ”
    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 Sunderland Royal Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to communicate changes in window restrictor fixing guidance to hospital trusts

    Wider context from the report

    “The fixing was attached to the sill of the window in accordance with fitting instructions issued by Jacklok and dated July 2017. Subsequent to the installation a data sheet was issued indicating that the fixing should be attached to the window frame only. This change in data/guidance was not highlighted to South Tyneside and Sunderland NHs Trust and presumably other hospital trusts. The position of the fixing on the sill enabled the restrictor to be more readily defeated bearing in mind this was a pivot window Jacklok have been requested to take action as follows (a) To ensure that the guidance is changed clarify the necessity to attach the fixing to the frame and proximity to the points of pivot (b) To ensure that this is effectively communicated to and highlighted with all NHS Trusts and other relevant users using the Jackloc window restrictor system The relevant Department guidance is Health Building Note 00-10Part D Windows and Associated Hardware ”
    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