The Western Trust has apologised to the family of an 83-year-old woman who passed away in Altnagelvin hospital after she was found lying on the floor beside her bed.
The Trust also told the sons and daughters of Brigid Cavanagh from Foyle Park in Londonderry that it accepted the recommendations made in a report into the circumstances of her death.
The apology came during the opening day of an inquest in Limavady that Mrs Cavanagh's family had requested.
They had concerns that a broken hip she suffered in a fall at home five days before she died on July 20, 2016, was not noticed in an X-ray taken at hospital on July 15.
The family are also hoping the inquest will provide them with an explanation as to how she was able to get out of her bed while she was in extreme pain, frail, in a confused state, attached to an oxygen tank and had a catheter fitted.
Mrs Cavanagh's son Paul said in court: "All I ask is that someone examines their conscience, because there is no way she either climbed down to the bottom of the bed or climbed over the side and disconnected her oxygen."
Coroner Patrick McGurgan heard Paul Cavanagh cared for his mother at home on a 24-hour basis because she suffered from chronic heart and renal failure and was extremely confused - to the extent she didn't recognise her sons or daughters.
He said his mother fell at home on July 15, 2016, and was taken to Altnagelvin hospital where an X-ray did not show she had broken her hip, but she was admitted to a hospital ward.
Mr Cavanagh told the court that over the following days until July 19, he was anxious about his mother, who was becoming more agitated and he wanted her back home.
At 5.50am on July 20, Mr Cavanagh received a telephone call telling him his mother "had taken a turn for the worse", advising him and the rest of the family to come to hospital.
This call was followed 10 minutes later by another informing him his mother had died.
The court heard evidence from an auxiliary nurse and a staff nurse working the night shift about how several checks were made on Mrs Cavanagh after she pressed her buzzer and said she wanted someone to stay with her.
One nurse said she explained she "could not stay" but she tried to "reassure her we were close by".
When asked by Mrs Cavanagh's son Vincent if she could explain "how a frail woman with a broken hip in an elevated position ended up on the floor?" the staff nurse said she could not.
Staff nurse Paul McCready dealt with Mrs Cavanagh's admission to the ward.
He carried out a risk assessment based on information from the acute medical ward where Mrs Cavanagh was being transferred from and his own observations. He told the court: "If I thought she was capable of climbing out of bed I would have used sensory alarms." But he said his decision was based on the information he had at that time.
The court also heard that the ward did not have sensory alarms for every bed on the ward and that they were allocated depending on how likely a patient was to get out of bed.
Mr Cavanagh asked Mr McCready if he could explain how his mother got out of bed. He also said he had no explanation.
Mr McCready said in hindsight it would have been better to place Mrs Cavanagh in a different room nearer the nurses' station where she could have more easily been observed.
Mr McGurgan asked Mr McCready about the staffing levels on the ward and was told that on the day shift there would be two nurses per six patients in a ward of 25 during the day.
But after midnight it was four nurses for all 25 patients.
The legal representative for the Western Trust told Mr McGurgan the inquest was due to hear from its director of nursing, who would be in a position to answer his question.
The inquest continues.