Pinderfields criticised after 84-year-old died following fall from hospital bed
Mary Ann Lincoln, 84, suffered an open fracture to her leg and had been on the floor "for some time" before a staff member happened to notice her as they walked by.
A Prevention of Future Deaths Report (PFDR) criticised the hospital for its lack of guidance and policy when it came to checking on patients who could potentially fall from their beds.
Mrs Lincoln had been placed in a single room at around 10.30pm on May 20, 2020, and it was known that she would often get herself out of bed so bed rails needed to be placed in the up position.
It was also known that she needed walking aides.
Reports show she had been given a "significant underdosage" of her medication for congestive cardiac failure, which could have contributed to breathlessness and the increased need to go the bathroom.
She was last seen at 2.40am the following morning, and her body found at 6.30am. Her bed rails were still in the up position.
The cause of death was found to be atrial fibrillation, pulmonary hypertension, ischaemic heart disease, and a traumatic fracture of right tibia and fibula.
Assistant West Yorkshire coroner, Lorraine Harris, gave a narrative verdict with contributing factors including her vulnerability and that she had not been given sufficient medication.
She also criticised the bed falls policy at the hospital and the failings of the bed rails to prevent her falling.
The PFDR read: "The hospital conducted a serious incident review in which it recommended the checks policy should be reviewed.
"It appears it was reviewed but no changes were made. Evidence had been heard that previous rounding checks were deemed inappropriate and therefore no further action was required.
"Therefore there is no policy or guidance with regard to people who are vulnerable, a falls risk and known to get up in the night (for any reason) to be further assessed for checks overnight."
The report found a comprehensive bed rails policy was in place, but staff responsible for implementing its use were either unaware of it or found it confusing.
Ms Harris said: "In my opinion action should be taken to prevent future deaths and I believe your organisation (Mid Yorkshire NHS Trust) has the power to take such action."
The trust has 56 days to respond.