A 78-YEAR-OLD woman died after hitting her head during a fall in hospital, an inquest heard.

A three-year investigation was launched into the actions of the doctors and nurses who treated her, which revealed doctors had failed to record Ivy Jones' fall in medical notes, staff on the following shift were not told she had fallen and a clinical incident for on the fall was not written.

An action plan followed, highlighting ways communication and documentation must be improved.

An inquest into her death yesterday revealed she died from head injuries sustained when she got out of bed and fell at the Royal Gwent Hospital in 2006.

She was admitted on October 14, suffering from breathlessness and was connected to a heart monitor.

Later that day Mrs Jones, of Pontllanfriath, told a nurse she needed to use the toilet and while the nurse was fetching a commode she got out of bed, fell over and hit her head.

The inquest heard she sustained a bump on her head but hospital staff were satisfied she had suffered no ill effects from her fall and helped her back to bed.

Mrs Jones complained of a headache and nausea over the next two days and on October 16 doctors carried out a CT scan, which revealed she had suffered a brain haemorrhage.

She died at 4.40am on October 17.

A postmortem revealed she died from a brain haemorrhage consistent with a blow to the head.

Gwent coroner David Bowen recorded a verdict of accidental death and said he was satisfied with the report carried out on the incident.

After the inquest, Mrs Jones’ sons Robert and Alan said they were upset it had taken three years for the report to be completed enabling their mother’s inquest to take place, which had prevented them having closure over her death.

Robert Jones said: "I hope they have learnt their lessons from this and will implement what they say they will."

The incident investigation report said the two doctors who failed to record Mrs Jones’ fall in her medical notes will be supervised at documenting notes - although the fall was documented in nurses’ notes.

A nursing handover sheet has been introduced to ensure all essential information is handed to the next shift.

Staff have been educated on their responsibilities for documenting evidence and the doctor who failed to write a clinical incident form has been advised of the Trust’s policy.

A spokesman for the Aneurin Bevan Health Board said: "As is our policy, a full internal enquiry took place when the accident occurred three years ago.

“As a result of this, all key issues relating to this lady's unfortunate fall were reviewed and addressed.

“We accept the coroner's verdict and we will look closely at comments made during the inquest."