New procedures have been put in place after mistakes were made by Altnagelvin Hospital medical staff in the care of an 83-year-old woman who was found dead on the floor beside her bed, an inquest has heard.
Brigid Cavanagh from Foyle Park in Derry died on July 20, 2016, five days after she was admitted to the hospital following a fall at home where she suffered a broken hip bone.
Yesterday, the Coroner's Court, sitting in Limavady, heard that Mrs Cavanagh's body was lifted from the floor where she was found and placed back on the bed, which was against hospital procedures.
There was also a delay of several hours before a doctor pronounced her dead.
The inquest also heard that staff failed to detect the fracture on an X-ray, delayed a blood transfusion, and filled "incorrect" information into admission forms.
Other important data was not entered at all within the recommended time frame and there was a failure to keep the family informed.
The family also raised concerns about how their mother, who was "frail" and suffered from chronic heart and renal failure, was able to get out of bed, which had safety railings fitted.
Coroner Patrick McGurgan said the poor standard of note-taking is a "recurring theme" at inquests involving hospital trusts, along with poor communication to family members.
He said a "major issue" for Mrs Cavanagh's family was that nurses didn't pick up on incorrect information about the risk of her falling.
Mr McGurgan asked: "How can the public be reassured this won't happen again?"
He questioned how a nurse receiving the handover notes would know if they had been "filled out wrong".
In her evidence, Judith Houlihan, the acting assistant director for primary care in older people's services with the Western Trust, said that new procedures had been introduced.
Nurses are now required to complete notes contemporaneously.
Ms Houlihan also said patient notes were audited for accuracy regularly.
She admitted "clear guidance" on moving a body after an unexpected death was not followed for Mrs Cavanagh.
This was because staff on the ward did not know what the correct procedure was, while they were "nervous" about contacting the family to inform them of their mother's death.
Ms Houlihan said training had since been provided.
Mr McGurgan is due to return his findings into the circumstances around Mrs Cavanagh's death today at Limavady Court.