An elderly woman was left starving and in pain in a hospital bed for four days with a broken 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 because her operation was repeatedly cancelled.
Each day she was included on the trauma operation lists, Mrs Richards, a former cook, 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 list but was still classed as "nil by mouth" due to an administrative error.
She was eventually operated on but died soon after from a blood clot in her lung, among other symptoms.
The hospital's handling of the treatment of Mrs Richards was described by Sherree Fagge, one of the hospital's managers, as "far from satisfactory".
She went on to say lessons had been learned and the trauma lists system had been improved.
An inquest in Brighton was told Mrs Richards, from Brighton, was first admitted to the Royal Sussex in April after suffering a stroke.
On May 2 she was transferred to Southlands Hospital for rehabilitation.
On the night of May 4, Mrs Richards got out of bed at about 10.30pm and went to speak to nurse Christine Gillings.
Ms Gillings said Mrs Richards then walked to an adjacent room.
The inquest heard she lost her balance while in the unoccupied room and fell to the floor. Ward sister Sarah Bucktownsing told the inquest that at first Mrs Richards had not complained of any pain and said she and her colleagues could find no evidence of any injury.
It wasn't until the next morning that Mrs Richards, who had slept through the night, complained of pain in her right leg.
A bedside X-ray revealed a 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, found Mrs Richards died from a blocked artery, deep vein thrombosis, a fractured leg and a stroke.
Hilary Martin, one of Mrs Richards' two daughters, 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."
Brighton and Hove deputy coroner John Hooper said: "Doris Richards died on the second day after surgery for repair of a hip fracture.
"The surgery was carried out on the fifth day after a fall while in hospital for rehabilitation following a stroke."
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