Kathleen Brock died in August 2008 after falling from a moving Handi-Bus.
The 75-year-old had suffered a head injury after her first fall at her home more than a year before that.
She fell several more times in the months that followed — including from her wheelchair and her bed — while at the Association for the Rehabilitation of the Brain Injured.
A fatality report recommends that doctors, nurses and therapists who deal with seniors work more together.
It also suggests there needs to be a plan to graduate more geriatric specialists from medical schools.
The report also recommends improved training and communication standards for Handi-Bus drivers and employees at the brain injury association, particularly when staff have weak written English skills.
It also says wheelchairs and bedrails should be checked out regularly.