The death of a patient who suffered brain damage when he fell at Lincoln County Hospital has led NHS bosses to introduce new policies.
Eric Rowland, 75, who suffered from diabetes and chronic leukaemia, fell on Christmas Eve 2010 and was subsequently diagnosed with bleeding on the brain.
An inquest at Lincoln Cathedral Centre was told that he was too ill to undergo surgery and died on February 11, 2011, after contracting pneumonia. Mid-Lincolnshire coroner Stuart Fisher recorded a verdict of accidental death on Mr Rowland, who lived at The Rookery, Collingham.
But he asked United Lincolnshire Hospitals NHS Trust to consider a more structured policy on the use of bed rails.
Mr Fisher said: "What is clear to me is that the chain of events which led to the death of Mr Rowlands stemmed from an accident.
"Namely, he was in bed, he wanted to use his urinal, and unfortunately he lost his balance and fell out of bed, hitting his head.
"Manifestly, had there been bed rails he could not have fallen out of bed, save if he had panicked and tried to climb out."
Tracy Pilcher, deputy director of nursing for the trust, told the inquest several changes were made when the trust reviewed its "falls policy" two months after Mr Rowland's death.
The new policy seeks to assess patients' risk of falling within 24 hours of their admission into hospital.
The inquest heard compliance was initially poor with a figure of only 24 per cent which had improved to 91 per cent by July this year.
Ms Pilcher said the new policy also aimed to improve the treatment and record keeping for patients who suffer falls. She told the inquest that staff are given training on an ongoing basis and that falls by the elderly are no longer treated as a "norm".
Comparisons made with other NHS hospitals in the East Midlands showed Lincolnshire in the "middle of the range" for falls. The inquest was told Mr Rowland was originally admitted to the hospital on December 3, 2010, and had been due to be discharged only to suffer an initial fall which left him with a bump on the head.
A decision was made to delay his release but he later suffered a heart attack before falling out of bed on Christmas Eve.
Speaking after the inquest, Mr Rowland's son, Andrew, welcomed the coroner's investigation into his father's death.
Mr Rowland said: "We accept the verdict from the coroner, and with the coroner's persistence it is good to see the hospital have put new procedures in place to deal with the issue of falls and bed rails."