West Suffolk hospital death: Coroner's concern over fall from bed
A coroner has asked an NHS hospital to address her concerns over the death of a patient who fell out of bed on an "understaffed" ward.
Sheila Coley, 79, died at West Suffolk Hospital in July 2017, two weeks after she fell and broke her hip within hours of being admitted.
Her daughter said she blamed hospital managers for failings in her care.
West Suffolk NHS Foundation Trust said it had since introduced changes "to ensure this does not happen again".
Coroner Jacqueline Lake said there had been conflicting evidence about whether bed rails had been up at the time of the fall and asked the hospital to explain how information was exchanged between staff.
Returning a narrative conclusion, she said Mrs Coley died as a result of her injury.
Ms Lake also said she would "reserve the right to make a report" and gave the hospital 10 days to describe what action had been taken.
Nursing staff told the inquest that the ward had been understaffed when the grandmother of two, from Thetford in Norfolk, fell from her bed at 03:00 BST on 21 June 2017.
She had been admitted to the hospital in Bury St Edmunds the previous evening in a confused state and was sedated.
Mrs Coley had an operation on 23 June for a fractured neck of the femur. She died on 8 July from aspiration pneumonia after suffering from post-operative delirium. Other factors included type 2 diabetes, congestive heart failure and asthma.
After the hearing, Mrs Coley's daughter Lucy Wheatley, 47, thanked the court and said: "I needed the truth and I feel I have got that."
She said staff on the ward did not know her mother been given diazepam, raising the risk of falls, and added: "In no way do I hold the nurses accountable. I hold the chief executive Stephen Dunn and the board responsible as they have overall control."
Ms Wheatley said her father, Terry, who had been married to her mother for 50 years, had been "too upset" to attend the inquest.
A spokeswoman for the West Suffolk NHS Foundation Trust apologised to Mrs Coley's family and said preventing falls was "an issue" for many hospitals.
She added: "We made immediate changes to our practices at the time and as a result of the investigation, we have introduced further patient safety changes to ensure this does not happen again.
"For example, we have increased the level and speed of the checks that happen with a patient when they arrive in a ward, such as their need for bedside rails and a wanderguard. We've also carried out significant training and support with staff on the ward."
The spokeswoman said staffing levels were also reviewed "three times each day" and agency and internal bank staff were called upon, if needed, to ensure a "high quality service".