A coroner has voiced his shock at how the family of an 83-year-old Londonderry woman were led to expect that she would be discharged from hospital - but instead received a call to say she was dead.
Coroner Patrick McGurgan made his comments during the inquest into the death of Brigid Cavanagh of Foyle Park in Derry on July 20, 2016.
Mrs Cavanagh had been admitted to Altnagelvin hospital after she fell at home on July 15, 2016. She was found lying on the floor beside her hospital bed at 5.30am on July 20 where she had passed away.
Among the medical staff giving evidence was Jane Baranowski, a nurse on the acute medical ward, who admitted notes she took about Mrs Cavanagh's admission there from A&E were "wrong".
She said she "ticked every box wrong" in one of the assessment forms, but also admitted she wrote a second assessment which contradicted much of what was on the first. During a handover meeting when Mrs Cavanagh was transferred to Ward 42, she failed to notice the discrepancies in the two forms.
Ms Baranowski said her only explanation was that the ward was "very busy".
These errors followed evidence given on Monday that an X-ray of Mrs Cavanagh's broken femur bone had not been read properly.
Dr Abdul Hameed, Consultant Physician in Acute Medicine, admitted in court there was a lack of communication with Mrs Cavanagh's family.
While he was in the witness box it transpired that there was no written documentation of a multi-disciplinary meeting held about Mrs Cavanagh, during which her care plan was discussed.
There was also no record of a discussion about the possibility of Mrs Cavanagh needing a CT scan because she was complaining of extreme pain on her left side and could not put any weight on her right leg.
There was also no record of a mental health assessment ever being made of Mrs Cavanagh, even though it was noted that she was "confused" at times.
Mr McGurgan said if the family had been aware of all of the information - instead of being told she was going to be discharged on July 20 after she received a blood transfusion - they might have opted to stay in hospital with her that night.
He said: "One of the shocking things is that this family were expecting their mother to be discharged, then they get a phone call to say she is dead.
"The opportunity for them to have a discussion about staying with their mother was taken away from them.
"One of the things I have found as coroner with hospital deaths is the lack of communication with families."
The inquest continues.