It's been found shortcomings in nursing care at Taranaki Base Hospital, directly contributed to a 78-year-old man's fatal fall

Leonard Collett was taken to the ED in an ambulance in July 2020, and died awaiting transfer to a ward.

Collett fell from the edge of his bed - shortly after using the toilet unassisted - and suffered a cardiac arrest.

Coroner Ian Telford's found Collett's high risk of falling wasn't assessed - and he received no care plans.

He says the death fall was both foreseeable and preventable.

Health New Zealand Taranaki says the department was facing several resourcing issues at the time.