A HORRIFIED family took photos of the gangrenous pressure sore their ailing relative developed in hospital and showed them to medics.
The 77-year-old had been assessed as being at risk of pressure sores when he was first admitted to Swansea's Cefn Coed Hospital.
He was not re-assessed until after he had developed the buttock wounds two months later.
It was one of three failings identified by the Public Services Ombudsman for Wales in the care of the pensioner, who was admitted to Cefn Coed in November 2009 and died there four months later.
Abertawe Bro Morgannwg University (ABMU) Health Board, which runs the Cockett hospital, has apologised.
The other two failings concerned insufficient pain management and nutritional assessment.
Around a month before his death the patient, referred to as Mr O, had become unwell.
Three days later he was left in a chair all day long. That night, according to ombudsman Peter Tyndall, staff noticed that his "buttocks have started to break down and look very sore".
Referring to the failure to reassess Mr O's bed sore risk, he said: "Pressure sore assessment is a basic part of nursing care and it is difficult to understand how it was overlooked, more so as Mr O was already known to be at risk.
"Further, Mr O became unwell from February 11, increasing his susceptibility to pressure damage, and still no assessment was done. This was simply unacceptable, and was, as the nurse adviser has said, a serious failing."
Mr Tyndall said he had been shocked at the pressure sore photos, but judged the sore had then been properly managed.
Mr Tyndall did not accept a contention that food and water had been withheld from the patient, who suffered dementia and was believed to have had a stroke.
But he said Mr O was not referred to a dietician as he should have been, nor was his ability to swallow assessed.
"That referral should have happened and did not," said Mr Tyndall. "The health board has offered no explanation as to why."
Although Mr O's pain relief dosage was increased as the weeks passed, Mr Tyndall concluded that "it seems likely that his pain management was insufficient on occasions".
The ombudsman also criticised the ABMU-led review of the case.
He said: "In my view, the (ABMU) report simply offered up the views of the clinicians; there was no proper analysis of the care provided. It appeared to defend the actions of the health board, which is not its function."
Mr Tyndall has referred his findings to Healthcare Inspectorate Wales due to similar cases in 2011 and 2008 involving ABMU.
He also suggested ABMU pay Mr O's family £2,000 compensation.
An ABMU spokeswoman apologised to the family and acknowledged "shortcomings in important aspects of care this patient received, which fell well below the high standards expected."
She said no Cefn Coed inpatient had developed a pressure sore since September 2010, when a new initiative was implemented.
She said ABMU's hospitals now had "some of the lowest rates of pressure ulcers in the world".
The spokeswoman added: "The end of life care pathway used in 2010 is no longer used by the health board.
"We also have better mechanisms in place to assess and serve patients' nutritional needs.
"ABMU health board strives to continually improve the care and services we are able to provide for them, and to learn lessons when we do get it wrong."