A coroner has criticised Hobart's major hospital after the original medical records of an elderly patient whose death was being investigated were destroyed.
Doreen Mansfield, 78, died on August 2, 2015 at the Royal Hobart Hospital from complications of a fall in her room the day prior.
Mrs Mansfield was under a mental health order at the hospital and was at times immobile.
In findings published on Friday, coroner Simon Cooper found her care was of an appropriate standard but her supervision could have been improved.
The report noted it became apparent during the inquest that Mrs Mansfield's paper records had been destroyed.
"This is unacceptable. It certainly caused difficulty in a practical sense," Mr Cooper wrote.
Mrs Mansfield was admitted to the Royal Hobart Hospital in July 2015 and given a room in the department of psychiatric medicine, about 60-70 metres away from the nurses' station.
She fell on August 1, fracturing her left femur.
If Mrs Mansfield's room was closer to the station, her supervision "may" have been improved, the report said.
"There was a good deal of evidence in relation to the lack of staff and poor staff-to-patient ratios, which no doubt placed significant demands upon the dedicated treatment team," Mr Cooper wrote.
The coroner found no motion detectors were in Mrs Mansfield's room but they could have assisted in ensuring her safety, considering her lack of mobility.
"It is obvious that motion sensors would not have prevented Mrs Mansfield from falling. However, they should have been available for use," Mr Cooper wrote.
Mr Cooper also noted that Mrs Mansfield's room did not have a call bell on a cord, but this was in line with all other rooms in the psychiatric ward due to the risk of self-harm.
The report said improvements had been made to the hospital's psychiatric department following Mrs Mansfield's death, including assessing the safest option for patients in terms of unit placement, room type and room location.
Mr Cooper made one recommendation, urging the Royal Hobart Hospital to preserve all patient records until the conclusion of coronial investigations.
Australian Associated Press