Geoffrey Hill was waiting for test results in A&E at Dudley's Russells Hall Hospital when he fell from the trolley, on which the rails were down, in February.
The 82-year-old from Stourbridge arrived at A&E shortly after 10am and was immediately seen by a doctor, a coroner's report said. But he was still in hospital waiting for test results at around 5.30pm when he fell from the end of the trolley.
At around 9pm his condition deteriorated and he became unresponsive. A CT scan identified a "very large acute subdural haematoma" and he died in the early hours of the following day.
His cause of death was given as traumatic subdural haemorrhage.
Black Country coroner Joanne Lees has now sent a 'preventing future deaths' report to the National Institute for Health and Care Excellence (NICE) in which she raised a number of concerns about the pensioner's death.
The incident happened at the height of the second coronavirus wave while the country was in lockdown and NHS services were under extreme pressure.
Ms Lees' report said: "Mr Hill remained in the A&E isolation area for over seven hours without any falls risk assessment being conducted. He was placed on a bed trolley with the bed rails down and a call bell within reach. Mr Hill was not subject to any advanced observations prior to his fall. Mr Hill was noted on admission to be suffering with reduced mobility, having been ‘off his legs’ and was noted to be ‘mildly confused’ at times."
The inquest also heard there were no national guidelines on the use of falls risk assessments in A&E departments.
Ms Lees, who recorded a verdict of accidental death, added: "I am concerned that vulnerable and elderly patients in A&E can spend long periods without any falls risk assessments being undertaken placing them at risk."
Diane Wake, chief executive of Dudley Group NHS Trust, which runs Russells Hall, said: "We would like to offer our heartfelt condolences to Geoffrey Hill’s family on his very sad death while he was in our care in February 2021. We accept the coroner’s conclusion of accidental death.
"At the time, there was no national requirement or guidance on conducting a falls risk assessment in an accident and emergency department. Following Mr Hill’s tragic death, and the coroner’s recommendation, we have implemented a falls risk assessment for all patients attending our department."