Allan Taylor
11 Mar 2025 · Coroner David Place · Sunderland
The coroner's concerns
1. patient not within sight or sound of nursing station
“The evidence confirmed that the guidelines for Level 2 EICO observations, which required a nurse to be within sight or sound of [the deceased], were not complied with as [the deceased] was in a Side Room 1, which was not within sight or sound of the nursing station. It has been explained that the geography of that ward is such that this is the furthest side room away from the nursing station, and a vestibule is before it.”
2. lack of escalation to senior staff
“The evidence was that this was not escalated to the Matron or Site Manager, which may have resulted in the movement of an additional member of staff to ensure compliance with the EICO Level 2 observations.”
3. absence of assistance during bed exit
“The evidence was that had [the deceased] been within sight or sound for observations, it was likely that upon [the deceased] attempting to get out of bed, assistance could have been provided to him, which in turn may have prevented the fall.”