Marne Street Hospital has changed its policy and installed safety rails in response to the death of a wheelchair-bound patient who fell off a loading dock while smoking last year, a coroner's report says.
Otago-Southland coroner David Crerar found Agnes Sinclair (67) died at the Vauxhall aged care facility on November 23, after being injured in an accident while smoking outside the hospital four days earlier.
His formal report said Ms Sinclair had multiple sclerosis and used a powered wheelchair as her only means of independent mobility.
She had been a patient at Marne Street Hospital since May 2009 and was regularly allowed access to a sheltered loading dock at the back of the to smoke cigarettes.
The loading dock was split into two levels, one about 45cm lower than the upper deck.
There was no barrier between the levels.
On November 19, 2011 Ms Sinclair was given access to the dock by a staff member to smoke and left alone for about 10 minutes, during which time her wheelchair fell off the upper level on to the lower level.
She was strapped into the wheelchair and had hit her head when it tipped and fell.
She was taken by ambulance to Dunedin Hospital, where a subdural haemorrhage was diagnosed. Her condition deteriorated to the point where only palliative care was appropriate and Ms Sinclair was returned to Marne Street Hospital, where she died on November 23, Mr Crerar said.
He found it most likely Ms Sinclair was trying to dispose of her cigarette when she accidentally drove off the edge of the landing or overbalanced while leaning over it.
The wheelchair was not faulty but Ms Sinclair's ability to control it had deteriorated slightly in the months prior.
A Department of Labour investigation found Marne Street Hospital had been fully compliant with health and safety regulations, and had made improvements to lift patients' safety since Ms Sinclair's death.
A secure and sheltered smoking area was built at the front of the hospital and a safety rail installed on the loading dock, which had been closed to patients. Residents were no longer allowed to be left unattended while smoking.
Mr Crerar said it was not necessary for him to make any recommendations in relation to Ms Sinclair's death because the hospital had "learned" from it.