Prevention of Future Deaths reports
Regulation 28 report to prevent future deaths, reference 2021-0415. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Reference | 2021-0415 |
|---|---|
| Deceased | Edward Cockburn |
| Coroner | Karin Welsh |
| Coroner area | Newcastle |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Product related deaths |
| Organisation named | South Tyneside and Sunderland NHS Foundation Trust · City Hospitals Sunderland NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Newcastle upon Tyne Coroners MISS KARIN WELSH HM ASSISTANT SENIOR CORONER Civic Centre, Barras Bridge, Newcastle Upon Tyne, NE1 8QH Date: 10th December 2021 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Chief Executive City Hospitals Sunderland NHS Foundation Trust Sunderland Royal Hospital Kayll Road Sunderland SR4 7TP 1. CORONER I am Miss Karin Welsh, Assistant Coroner for Newcastle 2. CORONER'S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3. INVESTIGATION and INQUEST 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 4. CIRCUMSTANCES OF THE DEATH 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 5. CORONER'S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. 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. 6. ACTION SHOULD BE TAKEN The following action is required to avoid future deaths: (a) Create a procedure to record details of training delivered, when and to whom (b) Create a system to audit that procedure so as to ensure that all training has been delivered to all staff 7. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report namely 4th February 2022. I, the coroner, may extend the period Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed 8. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: • Family • South Tyneside and Sunderland NHS Trust and their solicitor I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 10 December 2021 Karin Welsh HM Assistant Coroner for Newcastle upon Tyne Newcastle upon Tyne Coroners MISS KARIN WELSH HM ASSISTANT SENIOR CORONER Civic Centre, Barras Bridge, Newcastle Upon Tyne, NE1 8QH REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Date: 10th December 2021 THIS REPORT IS BEING SENT TO: Managing Director The Jackloc Company Limited Alma Park Woodway Lane Claybrooke Parva Lutterworth LE17 5BH 1. CORONER I am Miss Karin Welsh, Assistant Coroner for Newcastle 2. CORONER'S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3. INVESTIGATION and INQUEST 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 4. CIRCUMSTANCES OF THE DEATH 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 5. CORONER'S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The fixing was attached to the sill of the window in accordance with fitting instructions issued by your Company 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 6. ACTION SHOULD BE TAKEN The following action is required to avoid future deaths: (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 7. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report namely 4th February 2022. I, the coroner, may extend the period Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed 8. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: • Family • South Tyneside and Sunderland NHS Trust and their solicitor I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 10 December 2021 Karin Welsh HM Assistant Coroner for Newcastle upon Tyne Newcastle upon Tyne Coroners MISS KARIN WELSH HM ASSISTANT SENIOR CORONER Civic Centre, Barras Bridge, Newcastle Upon Tyne, NE1 8QH Date: 10th December 2021 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Rt Hon Sajid Javid MP Secretary for State for Health and Social Care Department for Health and Social Care 39 Victoria Street London SW1H 0EU 1. CORONER I am Miss Karin Welsh, Assistant Coroner for Newcastle 2. CORONER'S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3. INVESTIGATION and INQUEST 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 4. CIRCUMSTANCES OF THE DEATH 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 5. CORONER'S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. 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 6. ACTION SHOULD BE TAKEN The following action is required to avoid future deaths: To consider the issues raised with Jacklok and review the relevant guidance accordingly 7. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report namely 4th February 2022. I, the coroner, may extend the period Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed 8. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: • Family • South Tyneside and Sunderland NHS Trust and their solicitor I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 10 December 2021 Karin Welsh HM Assistant Coroner for Newcastle upon Tyne
2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Miss Karin Welsh
HM Assistant Senior C-Oroner
Newcastle Upon Tyne Coroners
Civic Centre, Barras Bridge
Newcastle Upon Tyne
NE18QH
2 February 2022
Dear Madam
SAFETY AT E:VEFIY LeVEL
The Jackloc Company Ltd
Alma Perk
"WoOdway Lane
Clayb!"ooke Parva
Lultarworlh
LE17 5BH
United Kn~om
s.ales@jeckloc .corn
Fa,,;: +-44 (0)1455 220 565
lnguest touchlnJJ the death of Edward Cockburn
The Jackloc Company Limrted
Report to Prevent Future Deaths
R gulations 28 and 29 Coroners (lnve8tiqations) Regalations 20·13
·,vww.jaciljoc,ccro
Further to our previous correspondence in this matter, the purpose of lhls letter Is for me. oo
behalf of the Jacidoc Company Limited ("the Company") to provide its respomse to your Report
o.f 10m December 2021.
----·~---
Response to Report to Prevent Future Deaths
Your Report notified the Company that you had concluded the Inquest touching the death of
Mr. Edward Cockburn on 10'1 December 2021 and informed it of certain circumstances
surrounding his death as well as your concems regarding the installation of the Jackloc
restrictor fitted to one of the windows in a &Juice room at the Sunderland Royal Hospital. Your
Report noted lhat Mr. Cockburn fell from a window in the sluice room and that the fixl119 used
lo secure a Jackloc Mark 2 restrictor on the window failed.
In paragraph 5 of your Report you expressed your concerns and for ease of reference 1 set
lhem out again here -
T1Ht fixing w•s attached to the ,sjJI of the window in accordatJce wHh fitting in&tructloM
Issued by your Company and dated July 2017. Subsequent to the ln.stafliftlon a data
sheet was Issued indicating that the 'fixing should be attached to 1ml window frame
only. This change In data/guidance was not highlighted to South Tyneside and
Sunderland NHS Trust and presumably other hospjtal trv.sts.. The-posmon of the fi1dng
on the sill enabled the restrictor to be more easily defe,ated bearing In mind this was a
pivot window.
In paragraph S you set out the action that should be taken by the Company which I set out
here also and again for ea:se of reference -
The follow;ng action should bfJ taken to avoid future deaths:
(a) To ensure that the Guidance Is changed to clarify the necessity to attach the
fixing to the frame and proximity to the points ofpivot
(b) To ensure that this i• effactively communicatffd to and hlghlfghted with all NHS
Trusts and other relevant u.sers using the Jackloc window re.strictor system
;~'1{j'Sl1:t1-::-:J G_.., (~ r.~J ·:j!'tl-•~(I ~n f:,~ t) .;or 1:~ -:t•1:j ~~./-:11:"·5 ::;(;f'."1;_'::;Jl'·i' (tun' t:)•~1 1).-4 !:19(lf.-f~
. 1 , ori;,:~::,~l ,:~.:!•~, !::(' ,:,"\' :_ :-i~n, Ui .. r.-,•~,:: ·c.-:,:.. t1 ( ,:.,;~11 1:it"i~~ L~Gi' ~:f-=-'d u~I ~ ~:! 1-i, r"p:Ji:C•,1
Given that the Company had not been invited to provide evidence for, nor to appear at, the
Inquest as an interested person I am grateful to you and your Officer for having cJarified, by
email on 12 January 2022, that during the inquest no concerns were raised regarding the
restlictor itself but rather the positioning of the fixing; that during the evidence it became
apparent that guidance/fitting instructions ~sued by Jacklock had changed from July 2017 to
November 2019 as to where the part A locking body of the restrictor should be frtted; and that
South Tyneside and Sunderland NHS Trust seemed unaware of this change hence the action
set out in paragraph 6 of your Report. I am grateful to you also for arranging to forward a
number of photographs of the relevant window and fixing to inform the Company's response.
Had the Company provided evidence for the purposes of the lr1quest the-re are a number of
matters that it would have been able to clarify and which I wish to set out for the purposes of
this response, namely -
• The Company's window restrlctors are immensely strong and for one to fail is virtually
unheard of. Instances of failure are inevitably at a fixing point where the force is such
as to pull the fixing screws out.
• Given that the restrictor is dependent on the fixing point and how welt it is secured to
either a window frame or sill it can never be guaranteed to prevent the window from
being forced wide open.
• The Company does not install restrictors. It suppOes them to installers.
• So long as the restrictor is installed properly and the fixing points are secure it will
prevent a window from being opened too far, not only the ordinary course of use but
way beyond that - however t being dependent on fixings the restrictor will not prevent
the window from being opened wide by the application of significant force (which will
not result in the restrictor separating but may result In the fixings being pulled from one
of its fixing points).
• The fittlng fnstructions for the Mark 2 restrictor are supplied with the product and those
to which you refer are the 2017 version. In 2020 the Mark 2 product was rebranded
and although the technical specification was unchanged, its name changed to the
"Pros·. New fitting instructions were issued to coincide with the name change but the
instructions for securing the restrictor remained unchanged. It follows that the
instructions for fitting the restrictor in place have not changed since July 2017 and
(provided they are fitted correct1y) state accurately that the fixings may be secured to
either the window frame or the window sill, I attach a copy of the 2020 fitting lnstructions
for completeness.
• The fitting instructions provide instruction as to the width of the opening, with the
installer being given the option of fixing the part A locking body of the restrictor
(described, by reference to a diagram, as ·part Alt in the instructions) to either the
window frame or sill to l.imit the width of the gap.
• The instructions also set out the required maintenance procedure to ensure, for
e:ic:ample, that nothing is working loose and that there is no excessive "play".
• The data sheet is a technical document, and it is not supplied with the product but is
available on request. Typically, though not entirely exclusively, it is requested by
architects and designers.
I appreciate that you have highlighted that the fitting instructions allow for Part A of the
restrictor to be fitted to either the window frame or si 11 but the data sheet states, "Fit Part A
(looking body) to the fixed frame and Part B (swivel--cable foot plate) to the opening window
frame".
This does not mean that the restrictor is any less effective if~ in accordance with the fitting
instructions Part A is fixed to the window sill - always provided that whatever it is fixed to, it is
correctly fitted and secure.
Please be assured that in view of your Report the Company and I have very carefully reviewed
the fitting instructions and we are satisfied that they are suitable and fit for purpose. We
consider that it would be wrong to change them to remove ttie reference to the window sill
because the part A locking body can be fixed to the sill and to do so will be no less safe than
securing it to the window frame, atways provided that the following direction from the fitting
instructions is heeded -
"'Each installation project must be surveyed and evaluated prior to fixing the Jackloc window
restrfctor to determine the appropriate fixings/anchorage and of the designated restricted
opening. Care must be taken to survey each window/door to ensure that the general and
specif,c condition of the material(s) are sound and are not in disrepair to ensure that the
Jackloc can be securely fitted".
If, rather than follow the fitting instructions, the installer followed the fitting methodology set
out in the data sheet and secured the part A locking body to the frame then that would not
compromise the effectiveness or safety of the restrictor in any way, provided the following
extract from the data sheet is heeded -
"Great care must be taken to inspect each and every window to ver;fy that they are in a sound,
serviceabJe condition and to ensure the secure fitung of the Jackloc window restrlctol'.
I wish to make it very ciear that the Company and I understand fully the reasons that led you
to conclude that a Regulation 28 Report should be required, and we intend you no disrespect
in saying that, given everything sat out above, we do not propose to alter the fitting instructions
and. because the instructions are and remain suitable and frt for purpose it is not considered
necessary nor appropriate for us to communicate with Trusts and other users in accordance
with paragraph 6 of your Report.
What the Company has resolved to do Is to amend the data sheet to make it align it and ensure
it is consistent with the fitting instructions and from this point onwards all the data sheets we
supply will expressly allow for fitting Part A to either the frame or the sill (copy attached}. This
will avoid any confusion for those who have and may refer to both the fitting instructions and
the data sheets.
I wish to add that if you, Mr. Cockbum 1s famity and South Tyneside and Sunderland NHS Trust
have any continuing concerns I shall be most happy to discuss and address them. All are
assured of the Company's co-operation and willingness to assist in that regard.
(Mainag ni
. eetor)
····-····
· ·
For and on beh·a
t he Jackloc Company Limited
South Tyneside and Sunderland NHS Foundation Trust ,~1:k1 Sunderland Royal Hospital Kayll Road ' Sunderland Tyne & Wear SR4 7TP www.stsft.nhs.uk 20 January 2022 Private & Confidential Miss Karin Welsh HM Assistant Coroner for the City of Newcastle upon Tyne Civic Centre Barras Bridge NEWCASTLE UPON TYNE NE18QH ~ " " ,½,iC Lei~ , D~ Welsh Regulation 28 Report to Prevent Future Deaths - Mr Edward Cockburn I write further to your correspondence dated 10th December 2021 regarding your concerns identified during the Inquest into Mr Cockburn's death. As you are aware, "falls from poorly restricted windows", are classed as Never Events, therefore, constitute Serious Incidents (SI). Prior to the inquest the incident was fully investigated by the Trust and reported to the Police, Health & Safety Executive (HSE}, Care Quality Commission (CQC), Sunderland · Clinical Commissioning Group (SCCG) and Safeguarding Adults Team. Our internal investigation identified omissions in care with regard to the level of observation in place for Mr Cockburn and the lack of escalation of concerns around staffing levels. Immediate actions were undertaken to address these issues, along with remedial estates work to fit additional window restrictors and swipe card access to restricted areas in key areas across the Trust, which has now been completed. · At the inquest hearing, you heard evidence from one of the witnesses that staff appeared to be unaware of the Trust Enhanced Care/Observation Standard Operating Procedure (SOP)1 that was in place at that time. I would like to take this opportunity to inform you that this SOP was updated in December 2020 and is now entitled "Guideline for Enhanced Interactive ,Care and Observation (EICO) for Adult Inpatients". • 1 A tool utilised to ensure staff maintain an environment which is safe and reduces the risk to patients and others by providing heightened levels of observation for patients within stated criteria. You also heard evidence from another witness that training at that time had not been given to all relevant members of staff in connection with the SafeCare electronic staffing tool2 . Whilst information and training materials for both tools had been cascaded to staff when they were first introduced, there was no process in place to monitor that staff had accessed the information and training materials. You have identified the following action required to avoid future deaths: (a) Create a procedure to record details of training delivered, when and to whom; and (b) Create a system to audit that procedure so as to ensure that all training has been delivered to all staff. We have now agreed a mechanism to address these actions by utilising our existing Electronic Staff Record (ESR) system. We are developing E-learning packages for both SafeCare and EICO which will be uploaded to the ESR and easily accessible to staff. Staff who require this training will have an associated competency added to th~ir 1karning ··pro1ie ahd compliance matrix within ESR. This will allow the creation of reports to capture and monitor/auait completion of this E-learning at an organisational level, as well as a ward/department level. I would like to assure you that this work is progressing well and we intend to utilise this model to monitor the training achievements.when other new training programmes are introduced. As you will note, the Trust is addressing the shortfalls highlighted during the Inquest, in order to prevent future deaths in similar circumstances. Progress of the actions detailed in this letter will be overseen by Melanie Johnson, Executive Director of Nursing, Midwifery and Allied Health Professionals, who will also keep me briefed and report progress monthly to the Trust's Governance Committee. I trust this information provides assurance to you that the Trust has taken appropriate action to address your concerns with a view to improving patient care and safety and reducing the risk of ariy similar adverse incidents in the future. I would also like to take this opportunity to offer my sincere condolences to Mr Cockburn's family on behalf of myself and the Trust. · Yours sincerely 2 A tool utilised to help determine safe staffing levels by matching staffing levels to patient number, acuity and dependency of patients in real time.
See every Prevention of Future Deaths report matching South Tyneside and Sunderland NHS Foundation Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.