A retail and merchandising operations manager for a local bakery who died while at work in the early hours of August last year had slipped and fallen backwards on an oily and wet floor - hitting her head.
Ms Shella Lee Shin Shin, 39, who worked for Swissbake, was wearing a pair of her own shoes with soles that were worn out, instead of safety shoes, in the baking area.
She suffered severe traumatic brain injury from the fall and became unconscious.
She never regained consciousness, and was pronounced brain dead in hospital the next evening.
Yesterday, State Coroner Marvin Bay said Ms Lee's death was due to "an accidental fall".
The coroner said the incident underscores "the vital importance of conscientiously adhering to a practice of wearing safety equipment whenever any worker or manager is at a production floor, or other work area".
He added: "Falls and other industrial mishaps can occur in even the most innocuous of circumstances. The donning of appropriate safety equipment can do much to avert accidents, or mitigate the risk of injury or death should accidents nevertheless occur."
The coroner's inquiry heard that Ms Lee's job was to ensure there was enough ready-to-eat confectionery items on the Swissbake bread shelves at various outlets of the Cold Storage supermarket chain.
A power failure occurred on the night of Aug 20 at Swissbake's baking premises at Commonwealth Culinary Creations in Jalan Boon Lay.
At about midnight, Ms Lee, concerned that there would not be any ready-to-eat confectionery and pastries in the morning, arrived at the baking premises to ensure that operations ran smoothly.
Workers were mobilised to prepare bread in the packing area.
They had to spray an oil-based substance on the dough, before baking it into bread or pastries. Trays of the dough had been taken out from a freezer in the packing area and left to be defrosted.
But the defrosting process made the floor wet due to condensation. With oil and water, the floor around the packing area became slippery.
At about 1.15am on Aug 21, Ms Lee, who was 1.78m tall, was seen by a delivery driver walking past the entrance of the packing area towards a freezer, presumably to check on a batch of pastries that was being cooled.
The driver called out to greet her, and Ms Lee slipped and fell. Her head hit the floor with a heavy impact.
A Swissbake director, who was in the packing room, called for an ambulance.
A Ministry of Manpower investigator found that the floor of the bread cooling area was wet.
But there were no anti-slip floor mats or signs to warn workers of the wet floor.