An elderly woman died after slipping and falling in a hospital toilet cubicle.
Following an official probe, Huddersfield Royal Infirmary bosses have now been told her death could have been avoided.
Jeanne Elsie Summers, 78, fell and broke her ankle while a patient at the infirmary on July 14, 2013.
A coroner has ruled the tragic accident could have been prevented if the married mum of four had been assisted all the way.
Mrs Summers, from Dalton, had been helped on her Zimmer frame to the toilet door.
But she was then left by a male health care assistant to make the final few steps inside the room alone.
The report said she was wearing slippery socks and fell, causing an open fracture of her right ankle.
She underwent surgery but ten days after the nasty fall she sadly died.
Doctors concluded the medical cause of her death was bronchopneumonia but said the ankle break was also a factor.
Mrs Summers’ chronic lung disease was another factor.
At an inquest in Bradford in 2013, assistant coroner for West Yorkshire, Mary Burke, ruled the fall could have been prevented.
In April this year she issued the hospital a warning to prevent future deaths.
Mrs Burke, said the lack of mobility caused by the ankle break contributed to the development of the bronchopneumonia – which led to her death.
A so-called Regulation 28 letter was sent to Calderdale and Huddersfield NHS Foundation Trust - warning it the death could have been prevented.
The letter was sent in April but it has taken the Examiner four months to get access to a copy.
It raises a number of concerns around the incident and Mrs Summers’ care:
There appeared to be no assessment of her ability when the hospital discharged her on a previous admission earlier in July. She ended up being re-admitted the very next day.
Physiotherapy records at the time of her re-admission on July 7 were not thorough enough.
Mrs Summers was not required to wear slippers or slipper socks. In addition the health care assistant who supervised her trip to the loo did not ensure she was seated on the toilet before he left her.
The matron who investigated the incident had not been trained on how to do an investigation.
The coroner gave hospital chief, Owen Williams, 56 days to respond to the concerns with a plan of action on how it would prevent a similar incident in the future.
Mrs Summers left widow Albert and was mum to Jayne, Graham, Barry and Ian. At the time of her death, she also had two grandchildren and one great-grandchild.
Julie Dawes, director of nursing at Calderdale and Huddersfield NHS Foundation Trust, said: “We are taking forward the recommendations made by the coroner and again send our apologies to her family.”
