Norfolk's senior coroner says patients should be checked before being transferred between care facilities to reassure families their loved ones are fit to travel, following the conclusion of a five-day inquest.
Sections of CCTV footage from Cygnet Hospital was shown at multiple times during the hearing into Peggy Copeman's death, with witnesses questioned around Mrs Copeman's physical health before and during her transportation back to Norfolk.
The footage is among the last movements of Mrs Copeman, who was in a wheelchair, as she was brought to the private ambulance transferring her back to Julian Hospital.
Evidence was heard describing Mrs Copeman as "slumped forward", with Premier Rescue Ambulance Service staff telling the court Cygent staff she was asleep.
The court heard her family had raised concerns to Norfolk and Suffolk Foundation Trust and Cygnet Hospital, in Taunton, around fitness to travel the 280 mile journey to Julian House, in Norwich.
Evidence was heard the suspected UTI Mrs Copeman was being treated for was not a contraindication of travel and she showed no signs of being clammy or in respiratory distress before being taken to the ambulance.
In her conclusion, Norfolk's senior coroner Jacqueline Lake said it was important for patients to be checked, a policy the hospital said had been put in place following Mrs Copeman's death.
Mrs Lake said: "I am of the view it is important for patients to be checked out before travelling especially such a long distance to ensure they are fit to travel.
"Certainly for the health benefits of the patient at the very least in some way to reassure a family their loved one is indeed fit to travel."
An application was made to the court supported by the family for the release of the CCTV.
Dr Solanke, the ward doctor at Cygnet Hospital, said after watching CCTV had he seen Mrs Copeman slouched over he would have taken a physical observation before she left.
On the first day of the inquest, Adil Al-Mousawi, psychiatrist at Cygnet, said the 81-year-old had completed two of the three-day course of antibiotics for a urinary tract infection and the transfer was being carried out by a service the hospital had used before and there had been no concern for her physical health.
The consultant psychologist said following Mrs Copeman's death the hospital now requests all referring units to provide a formal physical health assessment prior to admission.
He added that it had also updated its discharge referral so a full physical examination is taken prior to discharge.
In addition, all out of area referrals units are asked to provide written consent from patient's families or next of kin.
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