An elderly woman was left in agony for 16 hours by nursing home staff who failed to report a fall that left her with a broken hip and should have led to emergency surgery.
A coroner ruled staff at the Regis Forrest Gardens home in Bunbury failed to provide appropriate care to 83-year-old Nola Daniel, who fell three times on Christmas Day 2009, breaking the top of her femur in the process.
Nurses failed to notice the fracture and, despite serious bruising to the frail woman's face, they delayed more than half a day before calling an ambulance.
Mrs Daniel eventually had surgery but died of complications just over a week later.
Releasing her findings after an inquest, coroner Sarah Linton said yesterday Mrs Daniel suffered unnecessarily because of the staff's blunders.
"The staff at Regis Forrest Gardens were caring and well-intentioned - however, they clearly failed to provide an appropriate standard of care," she wrote.
Regis, which runs about 45 facilities nationwide, has since changed its policies so any fall, regardless of injury, is reported to a doctor and physiotherapist.