Neglect played a part in the death of a disabled 74-year-old woman who was strangled by the safety belt of her wheelchair, an inquest jury has ruled.
Brigid O'Callaghan was found with a "posture belt" around her neck at the Bupa-run Amberley Court nursing home, Birmingham, in 2005, the inquest heard.
The jury found six "gross failures" in the care given to Mrs O'Callaghan, who was left unchecked overnight.
A verdict of accidental death to which neglect contributed was returned.
The jury at Birmingham Coroner's Court found that Mrs O'Callaghan, who was discovered on 28 October 2005, died of asyphyxia after slipping down in her wheelchair.
The failings it found included a failure to check on her during the night and her safety belt being incorrectly fitted.
The woman, who suffered brain damage in a road accident in 2003, had been due to spend a week at the Edgbaston home while her daughter and full-time carer, Ann, took a break.
The jury's foreman told the court: "Following a Halloween party...Mrs O'Callaghan was wheeled to her room by a carer and left there, still strapped into her wheelchair and unable to reach the buzzer."
Speaking after the verdict, the Birmingham and Solihull Coroner, Aidan Cotter, said he would write to various organisations to make them aware of various aspects of the case.
These include the Nursing and Midwifery Council and the General Medical Council.
The inquest was told that since her accident, Mrs O'Callaghan, from Sutton Coldfield, had needed a hoist to move her from her wheelchair to her bed.
West Midlands Police arrested a nurse and launched an investigation following the death, but no charges were brought.