She walked onto a stage to offer prayers to a religious relic and lost her footing at the back edge of the raised platform.
Retired school principal Mah Yoke Ying, 73, was knocked unconscious after she fell 1.5m, and died in hospital 12 days later of pneumonia following extensive head injuries.
In an inquiry into her death yesterday, State Coroner Marvin Bay said her death was a tragic misadventure.
An active member of the BW Monastery Society, Miss Mah attended an event organised by the Buddhist group on Nov 27 last year to commemorate the death anniversary of its founder, Venerable Ri Chang.
The annual event was held in the event hall of the Big Box shopping centre in Venture Avenue in Jurong, and featured the relic containing some of his remains, which society members believe to be sacred.
Initially, the relic was placed at the opposite end of the hall from the raised platform, but it was eventually transferred to a table on it.
There was a 45cm-wide space between the table and the back edge of the stage, which led to the 1.5m drop.
Coroner Bay said: "The morning segment of the event had showed that devotees had an extremely keen interest in circling the relic before it was installed on the stage.
"The extent of their interest in observing the circling ritual could have been seen by the fact that before 2.15pm, devotees had undertaken this ritual while guided by marshals controlling the human traffic to ensure that their movement proceeded smoothly in a clockwise motion."
At around 6.40pm, Miss Mah told her friend, Madam Ang Siew Woon, that she wanted to go on stage to offer prayers.
But she fell off the stage and was unconscious when Madam Ang went to her aid.
Her friend called for help and Miss Mah was taken to the nearby Ng Teng Fong General Hospital.
She developed a fever on Dec 5 and died four days later.
Coroner Bay said: "This case underscores the need for meticulous planning of various aspects of mass-participation events of this nature, where there would be participants of all ages, and likely some with mobility challenges or other disabilities.
"It is hence particularly critical to identify and eliminate, or at least mitigate, fall hazards."
Representatives from BW Monastery Society, who declined to be identified, were present at the inquiry.
They told reporters that measures are in place to ensure similar incidents will not happen again. For instance, safety volunteers are now deployed at such events.