Judith Gaye Flynn, 72, died at the Canberra Hospital in January 2019 after she suffered a head injury from a bed fall on the general medicine ward.

Her admission - where she presented with fluctuating cognitive functioning with a history of falling, among other conditions - was because of an earlier fall.

Mrs Flynn's daughter Dr Joanne Lane on behalf of the family said the findings "showed our mother was highly vulnerable and needed specialised care".

"Unfortunately, our mother didn't receive the care she needed," Dr Lane said.

"We deeply miss our mother and it is devastating that her life ended in such a terrible way."

In the latter part of her life, Mrs Flynn suffered from a range of illnesses, including delirium.

During her hospital stay, she was found wandering the corridors unsupervised and fell twice.

When a nurse found her on the floor after the second fall, she was unresponsive and scans later showed a large subdural haemorrhage with an associated midline shift. She died two days later.

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In his findings published on Thursday after an inquest in 2021, ACT coroner Glenn Theakston said the hospital failing to instigate various controls did not cause Mrs Flynn's ultimate fall.

He said, however, those failures increased "the risk of Mrs Flynn falling and the seriousness of any injury resulting from such falls".

"I am left with the strong impression that, notwithstanding the best intentions of staff, the hospital as a whole did not operate in a coordinated way to ensure that appropriate controls were put in place," Mr Theakston said.

The coroner said he made the conclusion "cognisant of the workload and organisational challenges experienced by staff, and the difficulties in managing a large and dynamic organisation".

He said the hospital did not inform Mrs Flynn's family about her penultimate fall, the decline in her cognition, or her wandering behaviour on the afternoon of her final fall.

"They were not given an opportunity to attend in response to that information and assist Mrs Flynn," he said.

Mr Theakston said the hospital contemplated but did not provide Mrs Flynn with a hi-low bed, which could be lowered lower than a normal hospital bed to reduce a fall's impact.

He also found that the hospital did not allocate an assistant in nursing who could provide more continuous supervision to Mrs Flynn.

"There was direct evidence that a request was not made as there was the intention to move Mrs Flynn to another room," Mr Theakston said.

That other room was one of high observation, which had a dedicated assistant in nursing. However, a bed did not become available before Mrs Flynn's final fall.

The inquest also examined whether the geriatric medicine ward could have provided more appropriate care. Mr Theakston found the evidence was unclear whether it could have.

However, he said there "is something uncomfortably incomplete about the way the evidence fell to suggest that a general medicine ward was adequate for the daily care of Mrs Flynn while the very controls contemplated to address her high risk of falling could not be implemented there".

Mr Theakston found that in relation to medical treatment, qualified and caring practitioners appropriately assessed and treated her.

She was also appropriately assessed as having a high risk of falling while at the hospital.

Mrs Flynn's daughter, Dr Lane, said the slow hospital response time during the coronial inquest "made a very challenging process more so, which is disappointing".

"Coroner Theakston and his associates have been respectful and compassionate towards our mother and family throughout the coronial process for which we are thankful," she said.

"We hope that the Canberra Hospital has implemented the appropriate measures so that people with a cognitive impairment receive the care they need to remain safe."

Since Mrs Flynn's death, changes at the hospital include purchasing more hi-low beds.

A flow chart was developed to help staff with the process of requesting such beds and "safety huddles" were introduced as part of handovers to discuss patients who are at risk of falling.

Online education about falls was also mandated for nursing staff in the general medicine ward and in the medicine division.

The coroner, who acknowledged the grief and anger experienced by Mrs Flynn's family, did not propose any recommendations based on the changes already made.

A Canberra Health Services spokesperson said the organisation extended its condolences to Mrs Flynn's family and it acknowledged "the grief, loss, and sadness that those who loved and cared for Mrs Flynn have experienced".

"Following Mrs Flynn's tragic death and internal clinical review process, we introduced a number of changes as highlighted in the coroner's report," the spokesperson said.

They said the health services would "continue to consider any further opportunities to improve existing systems and processes" and to keep improving the quality of services to patients.

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