Brigid O'Callaghan died two days after she was admitted to the Bupa-run Amberley Court Nursing Home in Edgbaston, Birmingham, after staff at the home failed to put her to bed.

Birmingham coroner Aiden Cotter heard yesterday how Mrs O'Callaghan, who was also known as Vera, was found by a housekeeper at the home doing her morning rounds on October 28, 2005.

Mrs O'Callaghan, formerly of Sutton Coldfield, had slipped down in her wheelchair and was asphyxiated by its strap which had caught her neck, the inquest heard.

Evidence produced at the inquest suggested that nobody had checked on her since approximately 10.45pm the previous evening, according to her family's solicitor Jonathan Peacock, of Irwin Mitchell.

In a statement, the firm of solicitors said: "The nurse responsible for Mrs O'Callaghan had admitted in a hand-written statement seized by West Midlands Police that she had not checked on her during the night or changed her incontinence pads as required by her usual care regime, and had fabricated a note in Mrs O'Callaghan's records the next morning suggesting that these checks had been done."

The statement added: "None of the care staff who gave evidence at the inquest had been trained in the correct use of the posture belt fitted to Mrs O'Callaghan's chair, nor had they been made aware of a previous alert circulated by the Medicines and Healthcare Products Regulatory Agency drawing attention to previous similar deaths."

Mr Peacock said after the inquest: "The family of Vera O'Callaghan have suffered a great deal as a result of their mother's tragic death.

"Having heard all the evidence, they are satisfied that while failings on the part of care staff are clear, they were substantially contributed to by a lack of any care plan being written for Vera, poor staff communications regarding her needs, lack of supervision of staff by management and inadequate staff training."

The jury returned a verdict of accidental death to which neglect contributed and cited six separate counts of gross failure.

Dennis O'Callaghan, Mrs O'Callaghan's son, said: "Although we feel that the inquest answered many of the questions surrounding my mother's death, we really feel that the nursing home is failing to accept all the lessons it needs to learn to make sure that this type of tragic incident never occurs again."