A coroner's demanded action at Bedford Hospital after the death of a patient who fell over and banged her head.
Pamela Evans, who was 87, became dizzy, fell over and fatally banged her head while being taken to the toilet.
She wasn't seen by a doctor for several hours and died a week after the fall.
Although coroner Amy Street, said her death could not have been prevented she was concerned that other people may die unless action is taken.
She's told the hospital there is a loophole in their procedures which needs to be addressed.
The coroner found that "despite the increasing concern of nursing staff, she was not seen by a doctor until for several hours; the relevant medical team was attending a cardiac arrest and the critical care outreach team was not called."
In her report, the coroner said: "If the relevant medical team is busy dealing with another emergency, a patient may still face delay receiving potentially life-saving measures, even if the critical care outreach team is called."
A spokesman for Bedford Hospital NHS Trust said that the hospital does not routinely comment on individual patient cases.