The NHS trust that runs Andover hospital says it has made changes to its procedures at an inquest into the death of an “amazing” grandmother who fell while unsupervised on one of their wards.

Loretta Ako, an acting clinical matron at Hampshire Hospitals Trust, apologised to the family of Helen Penfound after she fell in the toilet of Basingstoke hospital and fractured her left femur. A coroner found that this broken leg caused “further deterioration” and “reduced her ability to recover” from the impact of an earlier fall.

The trust has since introduced changes to its procedures to ensure this kind of incident does not happen again.

Recording a verdict of accidental death, coroner Jason Pegg said it is “quite obvious she [Helen] is desperately missed” and was “very much loved.”

Winchester Coroners’ Court heard on March 9 from Helen’s husband Tony, who spoke about the moments in the lead up to Helen’s first fall at their home in Andover. Tony, who is visually impaired, passed his wife on the landing just as she started to take the stairs.

He said: “I don’t believe she fell the whole distance. I think she slipped halfway down and hit her head.”

Helen was taken by ambulance to Southampton University Hospital, where she was found to have a subdural hematoma (blood on the brain) and had suffered a brain haemorrhage, which was described by consultant Dr Ryan Waters as a “significant traumatic injury likely to result in poor neurological outcome.” She responded well to treatment at first, and so was moved to Basingstoke Hospital.

Tony said: “In hospital at first she could greet me, say ‘hello darling’, and for quite a while we used to help feed her but she also tried to do that herself. For a while I thought she was recovering quite well.”

She was admitted to the Overton ward and had been assessed as being at a “high risk” of falls. As a result, she was placed under close observation by nurses, with a bay supervisor watching the ward “to ensure patients were not acting in an unsafe manner”. She was having therapy for the fall, which involved activities such as her being walked to the toilet and back.

However, on November 12, she fell unsupervised, with further falls occurring on November 20 and December 14. In the latter, she cut her head while getting out of bed. Loretta Ako, an acting clinical matron who worked on the ward at the time, said that each fall had been reviewed and that it was difficult to balance the needs of safety and recovery.

She said: “We have to encourage them to have some degree of functional independence but because of cognitive impairment she couldn’t make wise decisions about safe risks.”

On December 20, she was accompanied to the toilet by a nurse. The nurse briefly stepped out to get toiletry aids to change Helen’s pad, and in this time, Helen fell and fractured the neck of her left femur.

Ako admitted that the nurse “should have stayed, or asked someone else to get the toiletries,” adding: “I cannot say you can 100 per cent stop someone from falling while you are there, but a person should be there to alert others when struggling and ensure safety.”

Lisa Stevens, one of Helen’s daughters, said that she was “astounded” that her mother had been left alone.

She said: “We were told as a family never to leave her so I’m surprised the nurses didn’t have that as well.”

Ako offered her condolences for Helen, and said that she “can only apologise” that the nurse didn’t stay by her side. She said “a lot of learning” has come from the incident, “not just for the ward but for the trust.”

She said that all falls now saw debriefs involving multi-disciplinary teams, while falls co-ordinators have been introduced to inform how to monitor patients with complex issues. She said “more stringent” watch procedures had been implemented so that staff cannot leave a monitoring bay without handing over to someone else.

“We are now reviewing incidents,” she said, “and perhaps could have suggested what other steps could have been put in place after this fall.”

Following her fall, Karen, another of Helen’s daughters, said that she noticed “a significant decline” in her mother, and that it was “apparent she was withdrawing more and more.”

Her sister Lisa, who called Helen “an amazing nan to my sons”, said that her mother’s inability to be mobile after the fall “would have contributed to her giving up.”

Following the accident, Helen was moved to Andover War Memorial Hospital, and then Willow Court Care Home. It was here she passed away on April 19 2020.

Delivering his verdict, the corner said that Helen “loved and cared for others and was very much loved herself” and that it was “quite obvious she is desperately missed.”

Pegg said that the fall at her home “started a train of events which caused progressive deterioration”.

He said that she “should have been supervised when mobilising from her bed” at Basingstoke Hospital and that “the consequences in the long run of that fractured femur were further deterioration and that fractured neck of femur reduced her ability to recover.”

He said that both falls were the result of accidents, and declared a verdict of accidental death.