An elderly patient was given someone else's medication by mistake shortly before she died, an inquest heard.
Sarah Jane Hastie, 84, collapsed only nine hours after the mix-up took place on a psychiatric ward at Airedale General Hospital, Steeton, near Keighley, last November.
But the widowed mother-of-four, who had a history of high blood pressure, died from heart disease and not because of the error, the hearing was told.
But Bradford Coroner Roger Whittaker will now write to the hospital to outline how lessons can be learned from the incident.
The inquest heard how the error was made after a nurse was asked to help out in a ward.
Staff nurse Janice Illing-worth described in a statement read to the hearing how she gave out medication from a drug trolley while relying on another member of staff to help her identify patients.
When she realised her mistake, she informed the ward manager and house officer.
Mrs Hastie, who was moved to the hospital after she became verbally and physically abusive with staff at a residential home, was monitored but it was felt the drugs were unlikely to have a detrimental effect on her.
She was wearing an identity tag but the inquest heard that there was no policy at Airedale General Hospital to ensure all the patients on that psychiatric ward had one.
Coroner Roger Whittaker said the "maladministration" of drugs was a mistake, and he accepted they did not play a part in Mrs Hastie's death.
"In some respects, this was a coincidental situation that she died nine hours after the administration of those drugs which were prescribed to another," he said.
"In future, this specific form of identity tag should be checked by those charged with the responsibility of administering drugs," he said.
He recorded a verdict of death from natural causes on Mrs Hastie, of Morton Close Residential Home, East Morton, near Keighley.
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