Amelia Axup, 82, died after being pushed over by a fellow patient on her first night at The Sycamores care home in Ossett which had just two members of staff on duty.
Staffing levels at the home were criticised by West Yorkshire Coroner, David Hinchcliff at an inquest yesterday as he made recommendations for an urgent review by South West Yorkshire Mental Health NHS Trust.

Wakefield Coroner's Court heard that Mrs Axup, who suffered from vascular dementia, spent one night at The Sycamores on New Street on February 12 this year.

She had previously spent time at the home but this was the first time she was to stay overnight.

The inquest heard that just two members of staff were taking care of what is believed to be 14 residents that night. As one resident needed constant one-to-one care, that left just one staff member on active duty.

The court heard that night had been "challenging" for staff, with two male residents involved in a fight during which a punch was thrown and another woman found with facial injuries after a suspected fall.

Later a woman resident became agitated at noise in the communal lounge area. She began walking around telling other residents to be quiet. When she came to Mrs Axup, she pushed her causing her to fall.

Mrs Axup, a Belgian national who had lived in England since she was 29 was taken to Dewsbury District Hospital where she underwent surgery on a broken right femur. She died the next day.

Recording a narrative verdict, Mr Hinchcliff said: "It transpires that the standard night time staffing levels of two to run a 15-bed home with severe dementia patients is inadequate to meet the quality of care and the safety of patients which is a relevant factor in this death."

He added that he intended to write to the chief executive of the trust recommending a review of staffing levels.

Speaking after the inquest, Mrs Axup's daughter Jeanine Wynn, 62, said in tears : "There were so many issues that night and I just wish I had never sent mum there to stay."