The family of an elderly woman found dead on the floor of a hospital ward have said staff at Altnagelvin denied her her dignity and prevented them from saying a final goodbye.
Speaking after a four-day inquest, the family of Brigid Cavanagh, who died on July 20, 2016, said the Western Health Trust should be ashamed after the 83-year-old had died in "terror".
Yesterday they welcomed the findings of Coroner Patrick McGurgan, who criticised the staff caring for Mrs Cavanagh over a series of missed opportunities.
Mrs Cavanagh, from Foyle Park in Londonderry, had a complex medical history of chronic heart and renal failure.
She died five days after she was admitted to Altnagelvin Hospital following a fall at home in which she sustained a broken hip.
The coroner found that the staff caring for Mrs Cavanagh "missed opportunities" to provide better care and treatment for her, and that one nurse changed her account of what had happened on the morning she passed away.
Mr McGurgan said that Mrs Cavanagh "died alone" after suffering a terminal collapse and fell from her bed while "the cot sides were down".
The position of the safety cot sides had been a major factor of the inquest with hospital staff consistently insisting they were raised when they discovered Mrs Cavanagh lying on the floor.
Mr McGurgan found that one nurse had added to her original account of what had happened on the ward on the morning of July 16, 2016 to state that "the cot sides were up".
He was also critical of the general quality of the notes documenting the care given to Mrs Cavanagh - which he described as "completely unacceptable" - and of the level of communication staff had with her family.
He said: "Greater and immediate attention needs to be applied in these two areas."
The coroner also found that there was "insufficient consideration" given as to why Mrs Cavanagh's haemoglobin level was dropping and said this was "a missed opportunity" in her care and treatment.
He also said "too much emphasis" was given to Mrs Cavanagh's heart condition and "not enough to the pain in her hip" and that there should have been consultation with an orthopaedic surgeon.
He described the failure to send the patient for a CT scan on her hip as another "missed opportunity".
The staff's "dearth of knowledge" about the correct procedure to follow when someone dies unexpectedly was also highlighted.
Staff had moved Mrs Cavanagh's body before a doctor had pronounced her dead and before informing the Coroner's Office.
Mr McGurgan acknowledged the trust's apology to the family "at the very outset" of the inquest. He paid tribute to the "great dignity" shown by Mrs Cavanagh's family during the inquest and said the "love, devotion and care" they undoubtedly had for her was "truly remarkable".
Speaking on behalf of the family after the inquest, Mrs Cavanagh's son Vincent said the coroner vindicated their need to raise concerns about the way in which their mother was cared for.
He said: "Our mother had a right to care and dignity up until the time of her death and to have her family around her. This was denied to our mother and our opportunity to say a final goodbye was denied to us.
"We can only imagine the terror that she experienced on her own, dying on the floor in pain.
"Her death in this way was preventable and avoidable.
"This should not have happened and should never be allowed to happen again to another vulnerable person or their family.
"The treatment of our family and the behaviour of the Western Trust has been disgraceful, they should be ashamed of themselves.
"We have to thank the coroner and his office for the work they have done. They have clearly listened to all of the evidence and came to the conclusion the family had all along.
"We are glad our concerns have been addressed by the Coroner's Office but the Western Trust has a lot to answer for.
"It has been a long two years and throughout that time the Western Trust has not been assisting us in trying to understand the circumstances around our mother's death.
"There is an issue that needs to be addressed in terms of the narrative the health trust tried to present and mislead the inquest and cover up what actually happened.
"Their serious adverse incident process has been wholly inadequate and what we have heard this week is a damning indictment of the Western Trust.
"We are calling for the immediate implementation of a statutory duty of candour for the health trusts."