The death of a Staffordshire diabetic at a scandal-hit hospital was contributed to by a systemic failing to provide adequate nursing facilities and because of low staffing levels, an inquest jury ruled.
The jurors, who heard how Gillian Astbury slipped into a fatal diabetic coma at Stafford Hospital in 2007, found that the failure to administer insulin to the 66-year-old amounted to a gross failure to provide basic care.
Returning a narrative verdict after a two-day inquest, the 10-member panel also said the death was contributed to by the failure of nursing staff to record glucose levels, communicate properly with each other and read clinical notes.
In its verdict, the jury said: "Nursing facilities were poor, staff levels were too low, training was poor, and record-keeping and communications systems were poor and inadequately managed."
The inquest heard how Mrs Astbury, from Hednesford, died early on April 11, 2007, while being treated for fractures to her arm and pelvis.
The jury, sitting at Stafford's County Buildings, heard that the pensioner's blood sugar levels were not properly monitored and insulin was not administered on the day before her death, despite being prescribed by doctors.
The court heard that some of the nursing staff were not informed that Mrs Astbury was diabetic and some said they were too busy to check the patient notes at the foot of her bed.
Antony Sumara, chief executive of the hospital, has apologised for Mrs Astbury's care and the local NHS trust has admitted full liability in separate civil proceedings.
Stafford Hospital was previously the subject of a highly critical report by the Healthcare Commission and a subsequent independent inquiry found that patients were "routinely neglected by a trust that was preoccupied with cost cutting, targets and processes and which lost sight of its fundamental responsibility to provide safe care".
A full public inquiry into the operation, supervision and regulation of the hospital between January 2005 and March 2009 is set to begin next month.