An elderly woman was left starving and in pain in a hospital bed for four days with a fractured leg.
Doris Richards, 92, suffered a fall while at Southlands Hospital in Shoreham, fracturing her right femur.
She was transferred to the Royal Sussex County Hospital the following day but it was another four days until she was properly treated as her operation was repeatedly cancelled as other cases were prioritised.
Each day that she was included on the hospital's trauma operations lists, the frail pensioner was given nothing to eat and only allowed fluids by intravenous drip.
The day after she was transferred to Brighton she was not even included on the operations list but due to an administrative error was still kept nil by mouth.
She was eventually operated on on two days later but died soon after from a blood clot in her lung, among other symptoms.
The hospital's handling of Mrs Richards' treatment was described by one of the hospital's managers, Sherree Fagge, as "far from satisfactory".
She went on to say that lessons had been learned and the trauma lists system had since been streamlined and improved.
An inquest at Brighton was told that Mrs Richards, from Brighton, was first admitted to the Royal Sussex in April after having a stroke.
On May 2 she was transferred to Southlands Hospital for rehabilitation.
Despite being 92, she was placed in a ward for under-65s, Bluebell Ward, as it was the only one with a bed free.
In Mrs Richards' hand-over notes from the Royal Sussex, staff described her as confused, unsteady on her feet and requiring 24-hour supervision but she was still allowed to walk around the ward.
On the night of May 4, she got out of bed at around 10.30pm and went to speak to nurse Christine Gillings who was on her medicine rounds.
Ms Gillings said she talked to Mrs Richards who then walked off into an adjacent room.
The inquest heard that Mrs Richards lost her balance while in the unoccupied room and fell to the floor.
The ward sister Sarah Bucktownsing saw her fall and went to help.
She told the inquest that at first Mrs Richards had not complained of any pain and said that she and her colleagues could find no evidence of any injury as they checked her over.
It wasn't until the next morning that Mrs Richards, who had slept through the night, complained of pain in her right leg and the medical staff saw that it was badly swollen.
A bedside x-ray taken later that day showed the fracture and Mrs Richards was transferred to the Royal Sussex.
It was five days until she was successfully operated on.
Pathologist David Wright, who carried out a post mortem examination on Mrs Richards' body, found she died from a blocked artery, deep vein thrombosis (DVT), a fractured leg and a stroke.
The inquest heard from Dr Wright that the risk of developing DVT was exacerbated by long periods of inactivity, such as lying on a bed.
Following the death of her husband Les in 1968, Mrs Richards, a former cook, moved in with her daughter Gillian in Crayford Road, Brighton.
She has two daughters, Gillian and Hilary Martin, five grandchildren and nine great grandchildren.
Hilary Martin said: "Mum was a feisty woman who knew her own mind and was very independent but at the same time she was very loving and caring with her family.
"I am happy with the care she received in hospital and would like to thank all the doctors and nurses who treated her."
Recording a narrative verdict, Brighton and Hove deputy coroner John Hooper said: "Doris Richards died on the second day after surgery for repair of a hip fracture carried out on the fifth day after a fall whilst in hospital for rehabilitation following a stroke."
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