Manual lifting procedures have been tightened at a Llandudno Junction care home after an elderly patient fell out of a sling while being hoisted off her bed.

Mary Bacon, aged 95, hit her head on the hoist’s metal frame and was taken to hospital, but died 13 weeks later at a different home.

At an inquest in Ruthin, John Gittins, coroner for North Wales East and Central, said that although the former nurse died of pneumonia and cardiac failure he was satisfied that her condition had deteriorated since the incident. He recorded a conclusion of accidental death.

Mrs Bacon, who suffered from dementia, had been a patient at the Bryn Marl Nursing Home for over two years when the incident occurred in March, 2017.

She was being hoisted by carers Sue Rumens and Jill Harrison when she fell out of the sling. An investigation revealed that the wrong sling was being used as Mrs Bacon’s correct sling was in the wash. It was the wrong size – Mrs Bacon was less than 5ft tall – and had also been wrongly fitted.

The 95-year-old, whose head was bleeding, was taken to Glan Clwyd Hospital and later transferred to Llandudno Hospital. She was subsequently admitted to the High Pastures Home in Deganwy, where she died on July 5.

Roy Pugh, general manager of Bryn Marl, which can accommodate 40 residents and has 50 staff, told the inquest that all members of staff had regular training in manual handling, dementia care and safeguarding, with the sessions delivered by an outside agency.

Asking by the coroner what assurance he could give that no such incident would happen again, he said that each residents now had his or her own slings with their name tags on them and details of which slings should be used were displayed inside their wardrobe doors.

“We have learned a lot from this incident,” he said. “Tragic as it was, this was an isolated incident and I believe that some of the things we have put in place will strengthen the service.”

Mr Pugh said the manual handling training sessions lasted half a day but Mrs Bacon’s son Clifford Bacon and daughter Sheila Jones said they did not believe it was enough, especially as Conwy County Borough Council staff underwent two days of training.

“Half a day is totally inadequate and we believe it would not have happened if that had been the case,” commented Mrs Jones.

Mr Pugh told the inquest there had been no similar incidents since Mrs Bacon’s death , adding: “We probably have at least 1,000 such movements a month in Bryn Marl.”

After hearing that Mrs Bacon had had greater difficulty eating and drinking after the fall and her weight had dropped from 42 kilogrammes to 32, the coroner commented: “I am satisfied to a degree of certainty that that was the final straw and she was simply not able to cope with the trauma.”

In view of the steps subsequently taken by the home he did not feel it was necessary to issue a Regulation 28 report to try to prevent future deaths.