The death of a 41-year-old with Huntington's Disease was a tragic accident, a coroner has ruled.

William Chitty, who was known as Billy, was already suffering from an advanced stage of the life-limiting condition which causes progressive degeneration of the brain, resulting in stumbling and clumsiness, involuntary jerking of the limbs and problems swallowing. He was being looked after in Birling House care home in Snodland High Street, which specialises in patients with Huntington's and similar conditions.

Because of the difficulties he had eating, Mr Chitty had been fitted with a PEG - a feeding tube - so that liquid nutrition could be fed directly into his stomach.

When care staff noticed last July that the PEG had become slightly dislodged he was admitted to Maidstone Hospital for it to be refitted. That was done successfully, but while Mr Chitty was recovering on Pye Oliver ward he fell out of bed and crashed into the floor with his head.

A CT scan suggested some subdural haemorrhaging, but doctors were unable to be certain whether the haemorrhaging was new or a result of earlier tumbles.

During the course of the inquest it emerged that Mr Chitty had already been admitted to A&E eight times between February and July, several as a result of falls, and his sister Danielle Thompson said it was not uncommon for him to fall once or twice a week.

Because Mr Chitty could not control his movements, he could not lie still for the scan, so the images were difficult to interpret.

As he showed no immediate deterioration in his condition he was discharged back to the care of the nursing home.

However several days later, his condition did deteriorate. He was returned to the hospital where another scan confirmed he had suffered a brain haemorrhage. Palliative care was prescribed and at the request of his family, he was returned to the familiar surroundings of the care home, where he died on August 4.

Giving evidence, staff from the hospital confirmed they were aware that Mr Chitty was at a high risk of falling. They had placed him in the bay closest to the nursing station and ensured there was always one member of staff on duty in the bay, which catered for six patients, at all times. His bed had been lowered to the minimum height with the bed rails raised and foam protectors and cushions placed in the bed to prevent his involuntary movements causing him to injure himself.

However at the time of the fall, the curtains around Mr Chitty's bed had been drawn closed and student nurse Greg Muchenje, who was attending to the patient in the next bed, did not see Mr Chitty throw himself through a gap in the railings at the foot of the bed.

After the fall, Mr Chitty spent another night in hospital, where he was placed in a side room with a member of staff on watch with him. He was given a lower bed, closer to the floor, that had not previously been available, and mattresses were placed on the floor in case he fell out again.

Coroner Katrina Hepburn said she was satisfied that because Mr Chitty's condition had worsened after the fall in hospital that it was the cause of the bleed and not earlier tumbles. However, she also found the hospital had taken reasonable steps to minimise the dangers. The death of Mr Chitty, originally from Dartford, was, she said, a "tragic accident."