Isle of Man coroner says bed fall death was accidental
An Onchan pensioner died from "multiple injuries" caused by falling out of her hospital bed, an inquest was told.
The inquest in Douglas was told Joan Terry, 87, fell face first from her bed at Noble's Hospital last January.
She suffered face injuries, hypothermia, fractured ribs and internal bleeding, dying from her injuries a day later.
The Coroner of Inquests Alistair Montgomerie recorded a verdict of accidental death.
Mrs Terry, a resident at Elder Grange Nursing Home, Onchan, was admitted to Noble's Hospital, Braddan, on 11 January 2010 for dehydration and suffered from a history of falls and self neglect.
Her condition improved with treatment and the hospital were planning her discharge when she first fell on 25 January.
She had attempted to climb over the bed rails and fell, but suffered no injuries.
But Mrs Terry fell again on 26 January and died from her injuries the next day.
The inquest heard Noble's Hospital had carried out a full review into her death and found that "early opportunities for intervention by staff were missed and a more thorough assessment of Mrs Terry's needs could have resulted in a different outcome".
Noble's staff were criticised for not re-assessing the fall risk of the patient after the first incident.
Elaine Hayes, falls prevention nurse at Noble's Hospital, said Mrs Terry had been at significant risk because of her history of falls and refusal to co-operate with staff.
"No remedial measures were put in place after her first fall and a full review of the fall risk was not completed," she said.
Anthony Wareham, patient safety and clinical governance manager at Noble's Hospital, told the inquest that the use of bed rails was a major factor of the fall.
"There was an inadequate assessment of Mrs Terry's needs and no review of the use of bed rails after the patient's first fall."
"Lessons had been learnt by the hospital in improving standards of care to patients and a full review of the use of bed rails has been conducted."
Mr Montgomerie expressed his "deepest sympathies" for Mrs Terry's friends and family.