Dorothy Cardno (67) fell 25ft from the balcony on 11th March 2003 after being admitted to the hospital three days earlier suffering a minor heart attack.

In making the ruling on Monday, Nottingham County Court judge Richard O'Rorke said a similar incident in 2000 should have alerted the hospital to the need for a specific risk assessment of the balcony.

He also found safety measures on the balcony were 'wholly inadequate' to prevent confused, delusional or irrational patients from climbing through — despite evidence mentally confused patients were regularly admitted to the ward.

But hospital bosses insisted they were not at fault and have announced they plan to appeal the decision.

Unmonitored

Mrs Cardno suffered the late-night fall shortly after she was transferred to an unmonitored bed on an all-female ward.

Her family had expressed concerns about her behaviour including denial and uncharacteristic impatience to nurses on four occasions, but the judge said there was no evidence of her being confused or delusional.

The three-day hearing was told the incident happened as she returned from the toilet.

She ran through the ward and the balcony doors — which were left permanently unlocked — and is thought to have slipped through a gap in the balcony fall protection before plunging to the ground.

Wheelchair

She suffered severe orthopaedic injuries, which mean she now relies on her wheelchair most of the time.

One witness who found the pensioner described her as shouting 'I want to die', but the judge accepted she had displayed no suicidal tendencies either before or during her time on the ward.

Mrs Cardno said she had no intention of committing suicide and all she could remember of the incident was severe pain in her back.

"All I remember was they rolled me over and I felt a terrible pain in my back and I started to cry," she said.

'Simple'

The court was also told how, following Mrs Cardno's accident, the balcony doors were permanently locked and Judge O'Rorke said 'simple and relatively inexpensive' measures could have been taken before the incident to prevent unsupervised access.

In addition, he said the 'overall lesson' after a similar incident involving a mentally disturbed patient jumping from the same balcony in January 2000 was plain — highlighting two key issues that had a direct bearing on the case.

"The first is that it was relatively easy for such a patient to escape over the balcony for whatever motive; the second is that the staff even when fully alert to this risk and attempting to manage the patient were quite unable to prevent such an incident," he said.

But although the incident was reported to health and safety chiefs, no investigation was carried out and a risk assessment of the ward did not take into account the risk of a patient falling.

Disappointed

Sherwood Forest Hospitals NHS Foundation Trust — which runs King's Mill Hospital — will also have to fork out an expected six-figure sum in court costs.

Spokesman Steve Argent said the trust was very sorry for what happened to Mrs Cardno, although disappointed with the judge's ruling.

But he said bosses were pleased the judge had found no nursing staff to blame for her fall and that they had no reason to individually monitor Mrs Cardno because there was no indication she had been or was about to become confused.

"We are pleased that the nurses involved in Mrs Cardno's care have been completely exonerated of any blame," he said.

The trust now has 28 days to appeal against the judgment.

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