A coroner has stated she will not be making a report into preventing future deaths at a Norfolk hospital, after concluding an elderly patient who fell out of bed while unsupervised died of natural causes.
Doreen Scoles, 86, of Station Road, Great Fransham, died at Dereham Hospital on August 16, 2018, where she was receiving palliative care.
She had been referred there after being discharged from the Norfolk and Norwich University Hospital (NNUH) just three days before, when surgeons tried to save her foot after an arterial blood clot left it gangrenous.
She had suffered a fall in the NNUH Brundall Ward on the night of July 7 while unsupervised and required surgery after sustaining a hip fracture.
An inquest on Wednesday heard a member of staff had been unable to attend her shift at the hospital after being involved in a collision, and due to the short notice no other staff were available.
At the conclusion of the inquest on Friday, senior coroner Jacqueline Lake said she was satisfied that the hospital had a system in place to ensure there were enough members of staff on shift, and that due to circumstances they were one member of staff down on the night of the fall.
But she criticised the two risk assessments carried out by staff at the hospital - once on admission and another carried out daily by nurses.
Ms Scoles was deemed medium risk of falling on admission and high risk in the daily risk assessment checks, but the hospital said this did not change the measures in place to keep her safe.
Ms Lake said: 'I did find this confusing, I'm not clear as to why two risk assessments are required.'
She added: 'I do have concerns with the risk assessments carried out in the ward and I feel clarity is needed.'
She said the hospital had not contacted Ms Scoles's daughter, Shanie Creasy, 60, on the night of the fall and the reason for this was not clear in the evidence.
But she accepted the hospital's evidence that Ms Scoles's hip fracture from the hospital fall and the subsequent operation did not cause the arterial clot in her leg and that this was a spontaneous event.
Ms Lake gave the conclusion that Ms Scoles died of natural causes.
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