Prestatyn pensioner suffered a serious leg fracture while in hospital, an inquest heard

But the news that 71-year-old Harold Williamson had also fallen the previous day came as a surprise to hospital staff and the coroner when it was disclosed by his wife Jane.

Mr Williamson, a former coach driver and mental health worker, was admitted to Glan Clwyd Hospital on October 27 last year with severe heart problems. He also had other medical problems including type 1 diabetes and arthritis.

In the early hours of November 13, while a patient on Ward 4, he was found lying face down alongside his bed with a severe cut to his lower leg. The bone was visible and he underwent emergency surgery to stem the flow of blood from an artery.

He died two days later, the cause of death being given as cardiac failure secondary to chronic kidney disease, contribute to by anaemia and the tibial fracture.

Ward manager Lisa Campbell told the inquest in Ruthin that Mr Williamson, of The Boulevard, Prestatyn, had been sleeping in a reclining chair which he found more comfortable and that an assessment of the risk of him falling had been made on his admission to hospital.

She said no particular risk was identified and he had no history of falls, but Mrs Williamson said her husband had told her how he had fallen in a similar way while getting out of his chair the previous day and had told a member of staff.

Mrs Campbell said she was unaware of that incident and it had not been documented in the nursing notes.

Mrs Williamson also told Joanne Lees, assistant coroner for North Wales East and Central, that her husband was able to move the chair, but Mrs Campbell replied that there was a brake on it which could be applied by the patient.

Recording a conclusion of accidental death, Mrs Lees said she could not say whether the lack of a risk assessment after the first fall had contributed to his death or whether the chair had played a part.

“Risks can only be mitigated against if they are known,” she added.

Mrs Lees said that although she had initially been “troubled” to learn about the earlier fall and about the chair being able to be moved there was nothing to justify her issuing a Regulation 28 report to prevent future deaths.