An 84-year-old woman who died after falling from her hospital bed was only noticed when someone passed her room.
Mary Ann Lincoln, 84, died after a "significant underdose" of her medication caused her to need the toilet more often and feel breathless.
Now a coroner has criticised the fall's policy at Pinderfields Hospital in Wakefield, West Yorkshire.
A Prevention of Future Deaths Report (PFDR) found she was left on the floor for a "significant amount of time" before she was found dead with an open fracture of her tibia and fibula.
Wakefield Coroners Court heard Mrs Lincoln went to bed with the rails up at 9.30pm on May 20 and was checked at 2.40am before she was found dead at 06:30am.
Mrs Lincoln, who had a heart condition and a history of falls, was only checked once during the night, despite it being known she needed to get up to use the toilet, the report said.
In her findings, assistant West Yorkshire coroner Lorraine Harris, said: "Her bed rails were still in place. It was evident that she had lain there for some time.
"She was not discovered until 6.30, and then only because someone noticed as they passed her door."
The PFDR noted there was "no guidance or policy" with regard to overnight checks on patients classed as vulnerable, at risk of falling or who were known to get up in the night.
A bed rails policy was in place but the coroner said that evidence showed staff responsible for implementing it were either unaware of it or found it confusing.
She said: "The staff responsible for implementing its use were either unaware of it, or find it confusing.
"There is obviously a void between producing a policy and ensuring it is circulated and understood by all concerned.
The report concluded by saying that "action should be taken" to prevent future deaths, and that the organisation has "the power to take such action".
