Doctors suspected Sheila Brock, 85, had a pulmonary embolism when she was admitted to Hull Royal Infirmary on November 23 2015 with breathlessness and she was given a dose of blood-thinning medicine.
But due to a mix-up over records, it was the only medication she was given over the next two days, leading to a massive blood clot and fatal heart attack.
A nurse was unable to find the medication on the ward the morning after her admission and despite recording it on a “drug card” - meant to flag up any medication needs to pharmacists - it was not spotted.
The fact Mrs Brock had not had the drugs was only realised the following morning when the medication could not be found on the ward.
A serious incident review could not clarify why the pharmacist had not seen the drug card. One suggestion was that doctors may have removed it from the ward’s “pharmacy card box.”
The fact no medication had been given was not recorded by the nurse on Mrs Brock’s medical notes.
The investigation concluded that a “system failure” around the drug cards had allowed a culture to develop where nurses passed on responsibility for dealing with drugs to pharmacists.
Mrs Brock’s sister, Sandra, said the hospital had let her sister down “massively.”
She said: “She was just another number on the ward, she wasn’t treated as a person and that’s why nobody realised she hadn’t had her medication. It is appalling.”
The trust has now agreed damages, after Hudgell Solicitors took up the case. Solicitor Shauna Page said there was no verbal communication between the nursing teams, pharmacists and doctors, adding: “Effectively, care which made the difference between life and death was left to a card messaging system which failed.”
Mike Wright, chief nurse at Hull and East Yorkshire Hospitals NHS Trust, said: “We would like to apologise and offer our condolences once again to the family of Mrs Brock.
“We are very sorry that Mrs Brock’s care fell short of the standard we expect at the trust.
“The circumstances surrounding Mrs Brock’s death were investigated by the trust as a “serious incident” and the findings of the serious incident review have been shared with her family.
“Various learning points, both for individuals and for the organisation, have been identified and acted upon in the two years since Mrs Brock’s death.”