A watchdog ruled that Lincoln County Hospital treated an elderly cancer patient and her husband badly – then failed to put measures in place to prevent the same mistakes happening again.
Marjorie Bryant, who had a history of breast cancer, was admitted to the hospital feeling unwell, constipated and nauseous on October 16, 2009.
Doctors then discovered her breast cancer had returned. She suffered a heart attack while she was waiting for a biopsy.
It took hospital staff two days to tell her husband Ralph about the heart attack, even though he visited.
Hospital staff also failed to give her a bath for three weeks, did not monitor her diet, failed to provide treatment or advice over her constipation and took her to the discharge lounge wearing only a dressing gown, despite her husband arranging for her to be picked up from the ward.
She died at home under the care of the palliative team on November 28.
Mr Bryant was so concerned about the way the hospital treated his wife that he spent £10,000 pursuing a complaint against the United Lincolnshire Hospitals Trust.
His complaint has now been upheld by the Health Service Ombudsman. It has found the trust guilty of maladministration because it did not take sufficient action to prevent its admitted mistakes happening in the future.
A report on the case by the ombudsman, Martin Pike, said: "I have found that the trust failed to adequately remedy its acknowledged failings. I can understand how Mr Bryant remains aggrieved about his wife's experience at Lincoln County Hospital and disappointed following the outcome of the complaints process, given the maladministration I have identified.
"The trust failed to put right all of its failings.
"The injustice to Mr Bryant is this feeling of disappointment, his unremedied distress arising from the trust's acknowledged failings and his loss of confidence in the trust."
However, the ombudsman has ruled the trust should pay Mr Bryant only £750 in compensation, despite what he spent on fighting the case, because he could have been represented for free.
Darren Fernie, who represented Mr Bryant, said: "It is only because Mr Bryant was prepared to go all the way that we got this significant success It was a serious failure in the care of Mrs Bryant and it is important this doesn't happen to others."
ULHT bosses say they have now acted to address issues in the report.
Clare White, spokesperson for ULHT, said: "The Trust apologises sincerely to Mr Bryant for any distress caused during his wife's treatment in 2009.
"We accept the outcome of the investigation by the Health Service Ombudsman and have taken steps to address issues.
"These include ensuring completion of nutritional assessments, training and the use of a clear assessment process in the handling of complaints to remedy injustices.
"We will ensure timely investigations of complaints which will lead to apologies for specific issues where necessary.
"We are also introducing tools to improve our management of patient discharge, including audits of the discharge process and incorporation of patient and relative feedback."