Edward Cockburn died after falling from a window at the Royal Sunderland Hospital in March last year and suffering multiple injuries.

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An investigation found that the tragic death of a beloved grandpa after falling from a hospital window could have been avoided.

In March last year, Edward Cockburn suffered multiple injuries when he fell from the sluice room window of the Sunderland Royal Hospital.

An investigation by the Newcastle Coroner's Court found that the 81-year-old had left his hospital ward and managed to enter a "staff only" room that was supposed to be closed, then fell off the first floor.

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The four-day investigation ended on Friday, December 10, and the coroner Karin Wales discovered that Mr. Cockburn’s death was avoidable.

In her narrative sentence, she said: "Ed fell from the window of a lock room that was supposed to be safe and died. The door was opened.

"Through appropriate and timely enhancement of the nursing risk assessment and one-on-one observations, falls could have been prevented.

"This is equivalent to negligence, which occurs when the level of staffing is not recognized and is seriously substandard."

After attending the emergency department on March 12, Mr. Coburn was receiving treatment for mild pneumonia in the hospital.

The investigation learned that on the evening of March 15th, Mr. Kirkburn locked himself and five other patients in a compartment with an electrocardiograph, removed the cables from the machine and wrapped them around the handle, so that the staff could not Enter.

The security was called and managed to enter the room, then gave Mr. Cockburn to the caregiver to take care of him.

A security guard who was present said Ed told him that he believed "people were trying to kill him through the door."

But the nurse who was dealing with another patient at the time did not know this, and did not evaluate Ed after the incident.

Rochelle Bonicito, a medical assistant, said at the hearing on Monday that when the security guards left, Mr. Cockburn appeared to "settle down."

Ms. Bonicito and nurse Colleen Walton later took care of another patient who complained of discomfort. After "less than five minutes" they opened the curtains on the bed and found that Mr. Cockburn had left.

While looking for him, Ms. Bonicito walked into the lock room, looked out the window, and saw him on the sidewalk outside.

Mr. Coburn was rushed to the Royal Victoria Hospital in Newcastle for treatment, but died on March 25 10 days later.

An autopsy conducted by Dr. Peter Nigel Cooper confirmed that his cause of death was acute bronchopneumonia caused by multiple injuries and coronary atherosclerosis Covid 19 infection. There were many injuries in the fall.

Coroner Wales summarized her findings, saying that Mr. Cockburn’s death could have been avoided if he were to receive one-on-one observation by hospital staff.

She said: "In the evaluation after the first incident on March 15, 2020, Ed will be observed at level 4.

"This will lead to one-on-one observations, which in turn will prevent Ed from entering the lock chamber and falling to his death.

"A greater understanding of staff and managers of the major shortages identified by the safety care system will lead to a more rapid response to staff requests in order to facilitate these one-on-one observations when such requests are made."

South Tyneside and the Sunderland NHS Foundation Trust apologized to Mr. Cockburn's family because his care failed.

After the incident, Debbie Cheetham, director of patient safety, investigated the trust fund.

This identified a number of issues, including the level of staffing, the level of observation, access to locked sluice chambers, and opening of windows where Mr. Cockburn fell.

She also emphasized that when the confusion was noticed, Mr. Cockburn could not be upgraded to a medical review.

Melanie Johnson, Director of Nursing, Midwives and Allied Health Professionals at the South Tyneside and Sunderland NHS Trust, said: “There is no word that can fully express our regret over the events that took place on March 15 last year.

"On behalf of the Trust, I apologize to Mr. Coburn's family unreservedly for the pain and suffering they have suffered.

"The safety of our patients is the most important thing. We accept the findings of the coroner's investigation and admit that Mr. Coburn's care was faulty.

"For the relatives of Mr. Cockburn, this is a very painful time. Although the results of the investigation cannot alleviate the suffering experienced by his family, we hope that they will feel at ease about the actions we have taken and will continue to take."

Mr. Coburn’s family was present during the investigation and they said they “thank” their representative Bridget Dolan QC and the coroner.

The family said they were "very satisfied" with the results and admitted that they had made a mistake.

At the final hearing, their representative, Ms. Dolan QC, emphasized that the family “thanks to the staff for their efforts for Mr. Cockburn despite insufficient staffing or training”.

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