Chorley hospital has been advised to look at its staffing procedures after a woman died after falling while in their care.
Elizabeth Sheeran, 84, from Leyland, was admitted to the hospital after collapsing at her home in Stonecroft Road in November last year.
In an inquest into her death last week, Preston Coroners’ Court how Mrs Sheeran was in a confused state-of-mind during her stay and would often try to leave her bed in the night.
Giving evidence, Dr Naqvi, a consultant at the hospital, said she was receiving treatment for a chest infection, small stroke and irregular heartbeat.
Mrs Sheeran had six children and was living on her own after retiring as a kitchen assistant.
He said: “She remained in a stable condition throughout (her admission) and made some recovery.
“She was regularly seen by me and my junior doctor but unfortunately when I saw the patient on January 23, she had had a fall the night before in which she was found fallen outside the bed.”
On the night of the fall, Mrs Sheeran, was in a ward with 23 other patients that was staffed by two trained nurses, two healthcare assistants, and a further healthcare assistant who was offering one-to-one care for another patient.
But at around 2.55am, while a nurse and healthcare assistant were on a break and another was taking a bathroom rest, Mrs Sheeran fell out of bed.
Steven Doran, charge nurse at the hospital on the ward Mrs Sheeran was on, said: “The one-to-on healthcare assistant asked if she could leave to go to the toilet and I relieved her of her duty.
“Mrs Sheeran was having a restless evening and asked to call her daughter to come and pick her up. She was trying to climb out of bed. I was looking after the other lady on the other side of the room. She was trying to climb out of the bed at the same time.
“When I was putting the other patient back into bed there was a loud bang. I looked over to Mrs Sheeran and saw her on the floor.
“Staff breaks are up to the nurse in charge and that evening was quiet except for when the fall happened.”
Mrs Sheeran suffered a fracture to the left side of the femur as a result of the fall and was transferred to Royal Preston Hospital on January 25 for an operation.
After the operation she suffered a major heart attack and was transferred back to Chorley hospital for further treatment, but sadly died three weeks later.
She also had a subsequent fall on March 8 when she tried to get out of bed..
Giving evidence, Prof Gupta from Chorley hospital said: “During the admission the aim was to rehabilitate so she could go home or to an appropriate place.
“Previously she was living on her own and was mobile. She had suffered from a massive heart attack soon after the operation and I believe that was the underlying factor that related to heart failure. We were dealing with a lady who was coping reasonably well before admission.”
Recording a verdict of death by natural causes, coroner Simon Jones said: “In terms of staffing levels on the ward, I am satisfied with the explanation given that it was up to the person in charge of the ward to decide when people should take their breaks. He is naturally going to pick times when the ward is at its quietest.
“This was a coincidence that having allowed two members to go on breaks he found himself in a situation he was struggling to cope with and had two patients trying to get out of bed. This is something the trust might wish to look at.”