THE death of an elderly Cotswolds woman who fell in her care home last year was a tragic accident, a jury has ruled.

Audrey Thomas was residing in the Jubilee Lodge Care Home in Bourton-on-the-Water when she was found on the floor of her room on March 13 last year with a fracture which led to her death two weeks later.

The 89-year-old had spent only one night in hospital after her fall and was then sent back to the care home - where she was in pain and gradually deteriorated until her death from bronchial pneumonia. Gloucestershire Royal Hospital had detected the impacted fracture but decided surgery was not possible.

A full jury inquest had to be held for Mrs Thomas because at the time of her death she was subject to a deprivation of liberty order following a diagnosis of dementia in 2014.

Until the fall she had been "relatively mobile" but the home, in Meadow Way, had a falls plan in place due to her medical condition.

Jubilee Care Home's general manager, Angela Pearce, told the jury Mrs Thomas was found on the floor at 7pm that day by staff member Louise Coombes, who had gone to administer medication. She had been seen an hour earlier to be provided her evening meal.

Miss Pearce said that Mrs Thomas told the staff member she thought she had broken her arm but didn't know how she fell.

Emergency services were called with a subsequent call 20 minutes later and paramedics arrived to administer pain relief and transfer her to hospital.

Miss Pearce said the patient was returned to the home the following day with advice on her management, and a follow up appointment letter.

"It was obvious to staff that although Audrey wasn't complaining she was in pain," said Miss Pearce.

"She only had paracetamol and these weren't strong enough so we contacted the GP who prescribed a codeine syrup."

However Miss Pearce said as the days progressed it became clear Mrs Thomas was deteriorating and they called the GP on March 20 for further pain relief. A Butec patch was given.

Miss Pearce said "We did the best we could with limited co-operation from Audrey."

As the days progressed, said Miss Pearce, they knew Mrs Thomas wasn't going to recover so they began end of life care.

"We commenced Orimorph, informing the family that Audrey was nearing the end of her life and they would make her as comfortable as possible," Miss Pearce.

"We had a close relationship with Audrey and the family and I don't think there was anymore we could have done."

Dr Ian Donald, the hospital's consultant in old age medicine, told the court he was overseeing her care and was aware she was kept in overnight to be discharged the following day.

Senior coroner Katy Skerrett asked Dr Donald if there were any symptoms to indicate bronchial pneumonia that the post mortem revealed as her medical cause of death.

Dr Donald said there weren't.

"She was slightly wheezy in the night but by morning her stats were up to 91 per cent which was within normal range for a lady of her age," he said

"She didn't have a temperature and her chest x-ray was normal."

Dr Donald said it was more common to return dementia patients to their home as quickly as clinically possible because it is considered better for their welfare.

"There is a greater risk of harm in the hospital," he said.

The jury returned a conclusion of accidental death.