The death of a man weeks after falling two storeys from a balcony attached to the neurology ward of Beaumont Hospital has been ruled a “misadventure”, a coroner has ruled.
Dublin District Coroner’s Court heard on Tuesday that the man died from sepsis caused by pneumonia resulting from multiple severe injuries, “polytrauma”, suffered in the fall.
George Saurin (70), fell or stepped off an air conditioning unit on the edge of a maintenance balcony attached to the Beaumont Hospital Brigid’s Ward at about 8am on Monday, October 11th, 2021.
The man gained access to the balcony because a window on the ward was not properly secured, the inquest heard.
The coroner’s court heard that Saurin was hospitalised the prior Thursday after suffering a “seizure-like event”. The 70-year-old had, according to a consultant, experienced “rapid progression” of severe neurological conditions including Alzheimer’s in the year before his death.
His first of multiple attempts to “abscond” from the hospital took place on Friday, when Saurin successfully left Beaumont but was returned to the ward by his son, George Saurin Jnr.
Over that weekend, Saurin was “agitated” and demonstrated “exit-seeking behaviour”, a member of the medical staff told the inquest. He made a series of other unsuccessful attempts to leave the hospital.
On Monday morning, shortly after 8 am as staff on the ward relieved the night shift, a nurse noticed an empty bed. Investigating, the nurse discovered an open window hidden behind a privacy curtain.
Saurin had accessed the balcony, which was off-bounds for patients and medical staff, through the waist-height window. The window restraint device placed on the window was functioning normally but was in the open position – something which would require specialised tools to do.
Another staff member saw a patient walking along the maintenance balcony and alerted security.
The nursing staff attempted to communicate with Saurin, where he stood atop an air conditioning unit, but he fell from the balcony before staff could intervene.
The man suffered severe injuries from the two-storey fall from the first-floor balcony to the lower-ground-level gravel below. He was, according to security staff, responsive but not intelligible, and was placed in ICU.
Around two weeks later, on October 27th, Saurin was transported to Tallaght University Hospital for treatment for related injuries, including bladder rupture and pelvic fractures.
He later developed pneumonia, which developed into sepsis. The infection led to his death on November 29th. The pathologist’s report linked the infections back to the injuries he received in the fall.
The coroner, Dr Myra Cullinane, found the death was a case of ‘misadventure’, an accidental death with an identifiable risk – that of the openable window. She stressed that nobody was blamed by the verdict.
Cullinane rejected a submission from barrister Caoimhe Daly on behalf of Beaumont Hospital, who had contested the misadventure ruling, suggesting the facts better supported a finding of accidental death.
The coroner — along with every member of medical staff who testified at the inquest — expressed her condolences to the Saurin family.
Daly read into the record part of a letter to the family from the hospital, that Beaumont “sincerely apologise for the incident that occurred”.
The coroner endorsed steps the hospital has taken to address the possibility of a similar incident occurring again, including introducing bi-annual inspections of all window restraint devices, and installing higher grade devices on all windows.