A woman from Truro with severe dementia died after falling out of her bed on her first night on a mental health ward.
Sheenah Langdon broke her hip falling out of a bed at the Longreach unit at Redruth and died two days later at hospital in Truro.
A jury inquest in Truro on Thursday heard Mrs Langdon, 86, could no longer be managed safely at Redannick House care home and she was detained under the Mental Health Act and taken to Longreach.
Most inquests are heard without a jury but new laws introduced this summer mean that a jury must be present for cases involving anybody who was detained by the state at the time of their death.
Mrs Langdon was admitted to Longreach at 7.30pm on February 27 last year.
The jury at Truro City Hall heard she was found on the floor next to her bed at 7am the next morning during a staff handover.
Mrs Langdon was then taken to the Royal Cornwall Hospital but was deemed unfit for anaesthetic and died on March 1.
The jury of four men and six women asked if Mrs Langdon had been regularly checked by staff during her first night at Longreach.
Alison Morris, nurse-in-charge of Cove Ward at Longreach, told the inquest: “Yes, the minimum checks would be every 30 minutes through the night. The night duty would finish at 7.25am.”
When asked by the jury if there was any form of guard on the bed to stop Mrs Langdon falling out, Ms Morris said: “Due to the nature of patients we seldom use guards due to the risk of entrapment.”
The jury recorded a verdict of death as a result of an accident while suffering from histrionic and narcissistic personality disorder.
Speaking after the inquest, Ms Morris said: “We would like to extend our condolences and sympathies to Sheenah’s family and friends at this very difficult time.”