A coroner has criticised a Norfolk hospital for how it handled risk assessment checks after an elderly woman fell out of her bed in hospital while unsupervised.
The Norfolk and Norwich University Hospital (NNUH) said it has made changes to the way it assesses the risks for older, vulnerable patients since the fall in summer last year.
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 NNUH just three days before, when surgeons tried to save her foot after an arterial blood clot left it gangrenous.
An inquest into her death at Norfolk Coroner's Court on Wednesday heard she had been admitted to the NNUH on June 22 after she fractured her hip following a fall at home, which required surgery.
She then suffered another fall at the NNUH Brundall Ward while unsupervised on the night of July 7, and required a second operation on her hip on July 10.
Tracey Shaw, ward manager, told the court that the ward had to prioritise patients in greater need because a member of staff who was due on shift was involved in a road traffic collision and this member of staff's shift on Brundall Ward was not able to be filled at short notice.
Before Ms Scoles was taken into surgery Dr Indunil Gunawardena, consultant in older people's medicines, noticed Ms Scoles's right foot was cold but decided this was in keeping with her diagnosis of Raynaud's disease, a condition which causes cold hands and feet.
But on further examination the following day, it transpired that her foot had become ischemic - the blood supply had been cut off due to an arterial clot.
Despite efforts to remove as much of the clot as possible it was too late to save her foot, which Darren Morrow, consultant in vascular surgery, said in his statement to the court was 'likely an end of life event'.
The court heard the hospital had carried out a risk assessment of Ms Scoles's risk of falling on the day of admission, which was rated medium, and that she was not assessed again until July 15 - more than a week after her fall in the Brundall Ward.
Ms Shaw apologised to Ms Scoles's daughter, Shanie Creasy, 60, and stated the assessment should have been carried out the day after the fall - but that a lesson had been learnt from the incident.
She also said there was a second day-to-day risk assessment carried out by staff in which Ms Scoles was rated as high risk of falling, but that did not change the measures already in place to keep her safe.
Senior coroner for Norfolk Jacqueline Lake criticised the two different risk assessments that did not correlate with each other.
She said: 'It seems like paying lip service to paperwork.'
Ms Lake adjourned the inquest to consider the evidence and will reach a conclusion at a date that is yet to be fixed.
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