A pensioner broke her leg after using a faulty wheelchair in a Norfolk care home, then died weeks later in hospital.

The break was not detected until nine days after the suspected incident, when a doctor referred the 91-year-old for an x-ray.

Now Norfolk coroner Jacqueline Lake has ordered a report into the use of wheelchairs at The Heathers Nursing Home in Beccles Road, Bradwell, in 'an effort to prevent future deaths'.

Peggy Connor died on August 2, 2013 at the James Paget University Hospital in Gorleston.

The medical cause of her death was given as pneumonia due to dementia, and a fracture of the right shin bone.

An inquest yesterday heard how staff had put Mrs Connor in a wheelchair with a loose foot-plate that was angled away from her on July 3.

Care home manager Sonia Hornicar said an investigation found the foot-plate incident was the most likely cause of Mrs Connor's broken leg.

The wheelchair belonged to the care home, and Ms Hornicar said it is policy for carers to check wheelchairs before they are used and report any faults or log them in the maintenance book.

She added changes had been made in light of the incident.

But Kim Perry, a care assistant who left The Heathers last year, told the inquest: 'A lot of the time the foot-plates were missing and a lot of the time they were on the wrong chairs.'

Dr Joanne Adly, GP registrar at Newtown and Caister Medical Practice, first visited Mrs Connor on July 4, but did not refer her to hospital until a second visit on July 11.

She said she had no suspicion of trauma to Mrs Connor's leg on the first visit, and on balance felt taking a dementia patient to the unfamiliar surroundings of a hospital would do more harm than good.

An x-ray on July 12 revealed the break

Coroner Ms Lake concluded that Mrs Connor died of natural causes contributed to by a fracture to her right shin bone which was probably sustained on July 3.

Mrs Connor's three daughters Susan Bracken, Kathleen Blake and Margaret Simnett were at the inquest.

Mrs Bracken said of the outcome: 'It's not going to bring mum back but I'm glad we got some justice for her.'

Mrs Connor had moved to Great Yarmouth from Tyne and Wear in the 1960s.

She was well known in the town, and had previously worked as a toilet attendant at Wellington Pier and had been a regular at the Talbot pub and Palace Bingo in Gorleston.