Edward Cockburn · Prevention of Future Deaths report

On the 10th December 2021 I concluded an inquest into the death of Edward Cockburn an 81 year old gentleman who died at Royal Victoria Infirmary Newcastle upon Tyne on 25th March 2020. He had fallen from an upper storey window in what should have been a locked sluice room on Ward B21 at Sunderland Royal Hospital on 15th March 2020. The medical cause of death was:

1a Acute bronchopneumonia due to

1b multiple injuries

1c

II Coronary artery atheroma Covid 19 infection

My conclusion was that Mr Cockburn had died as a result of a fall from a window in what should have been a secure sluice room the door of which had been propped open. The fall would have been prevented by appropriate and timely enhanced care risk assessments resulting in one to one observations. This amounted to neglect and occurred at a time of unrecognised and significant substandard staffing levels

Edward Cockburn had been admitted to Sunderland Royal Hospital on 12th March 2020 for treatment for inter alia pneumonia. He was transferred to Ward B21 on 13th March 2020. Assessments pursuant to the Trusts Standard Operating Procedure for Enhanced Care/Observation were not carried out after 02.44 on 14th March 2020 despite further episodes of confusion including an incident when Mr Cockburn barricaded himself and five other patients into Bay 3 on Ward 21. This resulted in a failure to instigate level 4 observations most particularly after this incident. This enabled Mr Cockburn to access what should have been a locked sluice room because it had been propped open and fall from a window within. The fixing used to secure a Jackloc Mark 2 restrictor on the window failed. This was at a time when staffing levels were significantly substandard. Mr Cockburn subsequently died from injuries sustained in the fall

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.

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