THERE was a 'catalogue of errors' in the care the first Gwent Police female detective received at the Royal Gwent Hospital, an inquest heard.

Sheila Marguerite Graham, of Rogerstone, was the first woman to be made Detective Constable at Gwent Police when she was appointed in 1967. An inquest into her death held at Gwent Coroner's Court on Thursday heard the 83-year-old died on June 30 of this year at the Royal Gwent Hospital in Newport.

The court heard, Miss Graham, who had dementia was admitted to the hospital on May 4 after falling at her home and hurting her hip. Jenene Edwards, Miss Graham's niece, told the court her aunt became more disorientated in unfamiliar surroundings such as hospitals and told members of staff Miss Graham had dementia on her admission.

Miss Graham fell three times while in hospital on May 18, May 19 and June 5. Mrs Edwards said it was 'absolutely devastating' to see her aunt in pain and could see her aunt 'deteriorating' after the falls.

During the third fall Miss Graham fractured her knee.

Amanda Hale, a senior nurse, for the Aneurin Bevan University Health Board, gave evidence from the findings of a serious incident investigation report into the care of Miss Graham.

She said on Miss Graham's admission a risk assessment was carried out but part two of the process wasn't completed until after Miss Graham's third fall. She said there was 'no evidence' of a fall prevention plan.There was no evidence of a pain management plan or no dementia plan in place.

A post-mortem examination concluded Miss Graham's cause of death was a pulmonary embolism.

Coroner Wendy James returned a verdict of misadventure.

She said:"On the evidence before me, it is clear that there was a catalogue of errors and omissions in the care provided during her stay in hospital which led to three in-patient falls.

"Had she not suffered three falls in hospital the outcome may have been different."

Mrs Edwards after the inquest said: "As a family we are very pleased the hospital has dealt with our complaint and were very receptive throughout."

She said they hope the action plan now in place will 'minimise any risk' in relation to elderly people with dementia.

A spokesman for Aneurin Bevan University Health Board said: “Our thoughts remain with the family of Miss Graham. The Health Board has conducted a thorough Serious Incident investigation into the care Miss Graham received. We have met with the family and shared the findings of our investigation fully and openly with them.

“The Health Board has already taken corrective actions and steps to address issues raised through our investigation and these actions were positively recognised by the coroner.”