Arthur Whitfield, 83, from Colwyn Bay, died after falling from a bed or chair at Llandudno Hospital in October 2015.
A post-mortem examination found he died from a number of falls.
Recording a narrative conclusion at the inquest in Ruthin, Denbighshire, the deputy coroner said "many opportunities had been missed" to stop him falling.
Betsi Cadwaladr University Health Board carried out a serious incident review that revealed failings.
It is now looking at how it identifies patients at risk of falls.
The inquest heard Mr Whitfield was admitted to Glan Clwyd Hospital, Bodelwyddan, at least three times in October 2015 after falling.
On 21 October, he was transferred to Llandudno Hospital and while a fall eight days later was not witnessed, he was twice seen trying to climb out of bed.
He died on 30 October, with a post-mortem examination revealing bleeding on the brain.
Pathologist Dr Andrew Dalton told the inquest he did not die from a single fall, but "falls".
Following his death, the health board carried out a serious incident review and admitted a risk assessment was not carried out as promptly as it should have been.
"It beggars belief that after all the earlier incidents it could happen again," said North Wales East and Central deputy coroner Nicola Jones.
Recording a narrative conclusion, she said because there were so many falls, it was not possible to reach a conclusion of accidental death.
Ms Jones issued a regulation 28 report stating that until new methods are introduced, the risk to others still exist.
"If these matters are not introduced there will be future deaths," she added.
After the hearing, Mr Whitfield's daughter Elizabeth said the family faced difficulty in raising concerns with hospital staff.
A health board spokesman said: "We fully accept the coroner's findings and are reviewing the way we identify patients at risk of falls."
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