Edith Alden, known by her loved ones as Bunny, died in hospital after suffering a fall in the garden of The Limes in Hellesdon.
The incident, on September 13, 2021, happened after Mrs Alden, 89, had walked out into the garden unescorted through an unlocked fire exit patio door.
During the second day of her resumed inquest, Norfolk Coroner's Court heard that it came despite her care plan requiring her to be supervised by staff while moving around the home due to her being assessed as "very high risk" of falls.
The plan, which was set when she was admitted to the home in June 2021, stated: "Bunny uses her frame for support to move from one room to another with carer support.
"Bunny is monitored to make sure she remains safe."
This meant that while she was not required to be under permanent 1:1 surveillance, she needed to be supervised while using her walking frame - which did not occur when the accident happened.
Meanwhile, the court was also told that two weeks earlier she had suffered a separate fall - but that no changes had been made to her risk assessments.
Giving evidence to the court, Luke Evans, the home's deputy manager, said that since the incident a key code had been installed on the door to prevent residents from leaving the lounge without staff being aware.
Mr Evans said that after moving into the home, Mrs Alden gradually became more mobile and confident using her walking frame.
On the evening of the accident, she had been visited by her daughter who spent an hour with her in the garden but had left almost three hours before the fall.
The inquest continues.
Care home resident who died after fall should have been supervised
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10.04.2024
Edith Alden, known by her loved ones as Bunny, died in hospital after suffering a fall in the garden of The Limes in Hellesdon.
The incident, on September 13, 2021, happened after Mrs Alden, 89, had walked out into the garden unescorted through an unlocked fire exit patio door.
During the second day of her resumed inquest, Norfolk Coroner's Court heard that it came despite her care plan requiring........
© Norwich Evening News
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