A great-grandad who died after falling from a hospital window should have been under “continuous observation” on the night of the accident, an inquest heard.
Edward Cockburn suffered extensive injuries in the fall from a sluice room window at Sunderland Royal Hospital in March last year.
An inquest at Newcastle Coroners Court heard the 81-year-old left his hospital ward and managed to get into a ‘staff only’ room, which should have been closed, before falling from the first floor.
On the third day of the inquest, the head of nursing for the NHS trust which runs the hospital accepted that “the care provided to Ed by staff was inadequate”.
Barbara Goodfellow acknowledged that there were four missed opportunities to reassess the former miner and put him on ‘Level 4’ observations, which would have kept him under direct supervision by a member of staff and stopped him trying to leave.
Mr Cockburn, known as Ed, was being treated for mild pneumonia at the hospital after attending the emergency department on March 12.
The inquest heard that he spent two nights on a medical ward, becoming increasingly “confused”.
Bridget Dolan, representing Ed’s family, said there were four occasions when Ed “should have been reassessed” due to his behaviour.
These included him repeatedly asking for a certificate – referring to a Covid-19 negative result – so he could go home, and telling a staff nurse she was trying to “dupe him” as she was giving him his IV antibiotics.
The inquest has heard that on the night of March 15, Ed barricaded himself and five other patients inside a bay with an ECG machine, taking the cables from the machine and wrapping them round the handles so staff couldn’t get in.
Security were called and managed to gain access to the room before leaving Ed in the care of the nursing staff.
A security guard who attended said Ed told him he believed “people were trying to come through the door to kill him”.
But the nurses, who were dealing with another patient at the time, were unaware of this and did not carry out an assessment of Ed after the incident.
Healthcare assistant Rochelle Bonicito told the hearing on Monday that when the security staff left, Ed seemed “settled”.
Ms Bonicito and staff nurse Colleen Walton later attended to another patient who was complaining of being uncomfortable, and after “less than five minutes,” they pulled the curtain on the bed back to find Ed had left.
Ms Bonicito went into the sluice room while searching for him, and looked out of the window to see him on the pavement outside.
Ed was rushed to Newcastle’s Royal Victoria Infirmary for treatment but died 10 days later on March 25.
On Thursday Ms Goodfellow agreed with Ms Dolan that Ed should have been assessed immediately after the barricading incident, and that “you can’t do that by a quick glance”.
She also agreed that had he been assessed, he would have been put on level 4 observations and would not have been able to get to the sluice room window.
Ms Goodfellow said: “If he had been under direct supervision which he should have been, he wouldn’t have fallen out of the window. He shouldn’t have fallen out of the window.”
Ms Goodfellow was also asked by Ms Dolan, “To send away security staff who indicated their preparedness to stay without even asking them for their account was inappropriate wasn’t it?” She replied: “It was .”
Ms Goodfellow said she had “infrequently” seen ‘staff only’ doors being propped open and had sent out a reminder to staff since Ed’s death that it was “unacceptable”.
The inquest also heard evidence from South Tyneside and Sunderland NHS Foundation Trust’s Head of patient safety Debbie Cheetham, who investigated the incident.
She said: “From speaking to the staff on shift that night, they had the intention of sitting by Ed in the bay all night.
“There’s absolutely nothing documented but in their head, they had the plan that they would be continuously observing Ed that night.”
On how Ed could have got through the door to the sluice room, she said, “I asked each of the staff individually and they all said it was closed.”
But she said there was “nothing to indicate the door was defective”, adding, “My opinion always has been, and still is, that the door must have been open.”
Ms Cheetham also said that although the number of staff on the ward that night was “at the agreed, funded level,” the trust estimated there was a “very significant shortfall” of 51.7 care hours, based on the level of care some patients needed.
The inquest heard a statement from Ed’s eldest daughter Lyn, who said the trauma of what happened to her dad was “still with us”.
She said: “The thought of the pain he endured as he sat outside on the ground still gives me nightmares.
“We will never recover from what happened to our father.
“What happened to him was so wrong and not how he should have ended his days.”
The inquest, due to last until Friday, continues.