A jury at a coroner’s court has called for the introduction of CCTV and new monitoring arrangements for patients at Roscommon County Hospital.
The call came after a 52-year-old woman died five days after a fall down stairs in her wheelchair.
Special-needs patient Anne Macklin from Four Roads was due to be released from the hospital on 15 February 2010 when she fell.
She was discovered by medical staff under the wheelchair outside a laboratory.
The family of the woman, who also suffered from multiple sclerosis, had asked to be allowed stay with her.
However, this request was turned down because of outbreak of the winter vomiting bug.
Dr Michael Farrell, a consultant at Beaumont Hospital, said that while Ms Macklin later died from pneumonia, he did not think she would have died if she had not fallen down the stairs.
The jury returned a verdict of death by misadventure. The coroner said the fall down the stairs was a contributory factor to Ms Macklin's death.
They also recommended that when special needs patients are admitted again the hospital should arrange for a carer or assistant to be with the patient even if the hospital is in lockdown.
The jury recommended that CCTV should be introduced on the corridors of the first floor of the hospital and that consideration be given to the relocation of the nurses' station so that it was beside the entrance and exit to the ward.
Afterwards, Ms Macklin's family said they were pleased with the verdict, especially the measures proposed for carers to be allowed to stay with a special needs person.
It is understood that the family has settled a civil action with the HSE arising from Ms Macklin’s death.
The HSE said a review was carried out in the aftermath of the death and changes have been introduced.
These measures include the introduction of new doors near the stairs and a swipe card system.
A new process whereby the special needs service providers will supply specific information on patients at the time of their admission is coming into force on 1 June.
