,~1:k1 South Tyneside and Sunderland NHS Foundation Trust

Sunderland Royal Hospital Kayll Road ' 20 January 2022 Sunderland Tyne & Wear SR4 7TP 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.

Dear Madam 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 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 ·,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 ofthe 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 - howevert 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 ofthe 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 the Jackloc Company Limited