A multiple sclerosis (MS) respite home in Dublin did not follow instructions on how often to check a patient, an inquest has heard.
A woman patient died from asphyxia when her head caught between a mattress and the side rail of her bed.
Linda Ryan (46), of Chapel Lane, Malahide Road, Swords, Co Dublin died on February 27th last year, the morning after she was admitted to the MS care centre in Rathgar, Dublin.
Dublin City Coroner's Court heard yesterday that Ms Ryan suffered severely from MS and was completely immobile.
The court heard that it was a "mystery" how Ms Ryan, who had been placed lying on her side, ended up on the floor in an upright position with her head caught between the side rail and mattress of the bed.
Nursing staff told the court that it was impossible for Ms Ryan to have slipped under the side rail of the bed.
Tony Ryan, who also has debilitating MS, told the court that he discussed with a member of nursing staff the specific instruction that his wife was to be checked and turned every two hours.
Mr Ryan added that it was the first time during nine years of visiting the centre that he had not stayed with his wife.
Nurse Maria O'Brien said she wrote Mr Ryan's instruction on his wife's file before passing it on to a night nurse as she went off duty at around 10.30pm.
Nurse Anne Murphy told the inquest that after Ms Ryan went to bed at 11pm, she was turned at about 12.30am and again at about 4.30am.
Ms Ryan was discovered on the floor with her head caught between the mattress and side rail at about 9.20am.
Nurses had not checked her since they left her room at 4.45am after turning her.
Ms Murphy said she had gone to Ms Ryan's door at about 7am and considered turning her over but decided to let her sleep on.
"When it came to seven I made a professional decision to let her sleep.
"I decided not to turn her . . . In all the years I knew her she would never move in the bed."
She added that she knew Ms Ryan was supposed to be turned every two hours.
She finished her shift at 8am and care worker Rose Tucker discovered Ms Ryan at about 9.20am.
Ms Tucker said she found her on the floor in a "semi-upright position and the top of her head was between the cot rail and mattress".
When asked how she had managed to make her way to the floor, Ms Tucker said: "We have asked ourselves so many times; we really don't know."
Prof Sean Ó Briain, a pathologist at St James's Hospital, told the court that Ms Ryan died from positional asphyxia. She was taken to St James's Hospital but died the same day.
John Gleeson, legal representative for MS Ireland, told the court that staff at the respite home were at a loss as to what had happened.
"It is a complete mystery as to how this happened. "She couldn't have moved at all; she was completely immobile."
Coroner Dr Brian Farrell adjourned the inquest until September as Garda representatives who investigated the death were not present.