Manor House in North Walsham warned after resident's death

John Riley was found lying on his bedroom floor at Manor House in North Walsham on February 8 this year, with a bed frame under his neck.

Tragically, he died at the scene, with mystery still surrounding how and when he came to fall out of bed.

An inquest into his death was held last week. Senior coroner Jacqueline Lake concluded his death, from a neck fracture, was an accident.

However, following the hearing, Mrs Lake also issued a report to prevent future deaths surrounding staff observations at the home.

The inquest heard that Mr Riley had severely limited mobility owing to life-changing injuries he suffered in a road tragic collision in 1976.

He had been living at the home for more than five years and was dependent on others for care, but was deemed a low risk of falling out of bed.

Members of staff had to observe Mr Riley every two hours at night.

Jacqueline Lake, senior coroner for Norfolk (Image: Newsquest)

On the night of his death, observations were carried out at 1.10am and then again at 3am.

But it was not until 5.25am when he was found unresponsive in his bedroom, 25 minutes after he was next due to be checked.

And while evidence was heard that the home had taken action to try and reduce the rate of late observations, staff at the home were not always keeping them on time.

In her report, Mrs Lake wrote: "In my opinion, action should be taken to prevent further deaths."

Healthcare Homes, which runs The Manor House, has been contacted for comment.