A family's distress over the death of their sister was compounded by mistakes made by organisations responsible for her care, according to a coroner.
Susan Perry, who had Down's syndrome and dementia, died from natural causes in Leicester Royal Infirmary on February 25, last year, after contracting pneumonia.
An inquest at Leicester Town Hall heard it was "contributed to", but "not caused by" significant fractures on both sides of her hips.
Coroner Lydia Brown said a "paper trail disaster" meant the inquest was unable to identify precisely how these injuries came about.
She said it caused delays in the inquiry which also prolonged the pain felt by Susan's family.
The 64-year-old, from Braunstone Town, had lived at Milligan Court care home, in Aylestone, Leicester, since November 2011.
Having lived with her parents for most of her life, Susan needed 24-hour care due to the onset of dementia and inability to support her own weight.
On Saturday, January 12, last year, she had fallen ill and was taken to the infirmary by East Midlands Ambulance Service, where she was diagnosed and treated for a chest infection and returned to the care home.
Care workers had also on that day noted minor bruising on her thigh that day, which spread over subsequent days.
But it was not until three days later that Susan was admitted to hospital a second time, when her hip injuries were diagnosed.
She underwent a successful operation but, despite initial signs of recovery, her condition deteriorated and she failed to recover from a heart attack on February 21.
Judy Hodgson, Susan's sister and guardian told the inquest she was angry that care staff at the home had not informed the family about the bruising when it was first discovered.
The coroner said: "The home has apologised unreservedly for this and accept it was inappropriate."
"I take it further," she added, saying that had Mrs Hodgson known of the extent of Susan's bruising the diagnosis would have been made "some 36 hours earlier".
Milligan Court was also criticised for supplying inaccurate "body map" records.
Consultant orthopaedic surgeon Amit Modi said the severity of the hip injuries suggested they were caused by two separate falls.
But Mrs Brown said there was no evidence of a "cover-up", while a post mortem examination revealed Susan's bones were so fragile due to osteoporosis that independent medical experts said regular handling and lifting could have caused the fractures.
The inquest's efforts to rule out an unreported incident, however, were frustrated by the inability of both the University Hospitals of Leicester NHS Trust and ERS Medical patient transfer service to provide documentation to identify the ambulance crew which had returned Susan to the care home after her first hospital visit.
It meant that despite numerous preliminary hearings and a six-day inquest, which had to be adjourned for a month, this information was never established.
Mrs Brown said: "One of the measures of a civilised society is how we care for our most vulnerable members – our elderly, our disabled an dour sick .
"That I was unable to establish beyond reasonable doubt who returned Susan to her home due to poor record keeping, but had to rely on very detailed exclusion evidence is a very poor reflection on all those involved."
She added: "It has only added to the family's distress and the length of the inquest, and has not permitted clarity regarding what should have been the most basic of facts to establish: who was tasked with keeping Susan safe at each stage of her care."
Lawyers for the NHS Trust and ERS Medical apologised to the court and family, and Mrs Brown accepted that electronic systems were now in place to ensure it would not be repeated.
Speaking after the narrative verdict, Mrs Hodgson said: "Susie was a much-cherished sister and loved family member, and led a very fulfilling life.
"All we have ever wanted was for the truth to be told."
