Eighty-five-year-old Florence Weston was an active, outgoing person when she was taken into hospital with a fractured hip in December 2007.
She enjoyed living on her own and led a busy life.
But by Christmas she was dead, following repeated delays and three operations in 12 days.
According to her son Mike Weston she suffered "appalling care".
Florence's family were "shocked and horrified by her treatment".
Apart from a minor heart attack four years before, Florence was in good health when she fell and damaged her hip.
She was treated at Russells Hall Hospital in the West Midlands, where her son expected her to be operated on quickly.
But she was told day after day that she would have to wait for surgery.
Five days later Florence was taken to theatre but during that period she had not been allowed to eat or drink.
"It was a shocking state of affairs," says her son Mike. "I knew she should have had the operation within 48 hours and was very upset when she didn't, but I kept being fobbed off by the hospital when I asked what was happening."
"The pain of those first five days must have been terrifying for her."
The worst thing, Mike says, was his mother being told by nursing staff to wet the bed because she couldn't get up to go to the toilet.
"For a proud woman to be told that was an absolute disgrace," he said.
When Mike visited her next, his mother was in tears and demanded to be taken home.
When she was eventually operated on, the surgery was not done correctly and Florence had to be transferred to another hospital.
There she had to undergo another operation lasting between four and five hours.
In the end, says Mike, "she wasn't strong enough to deal with it all".
"If the operation had been done in the first 48 hours I think she would have had good chance of survival and been OK," he says.
But, at the time, the hospital told him there were other clinical priorities. It was only when Mike managed to speak to a senior consultant that things finally got moving for his mother.
Dudley Group of Hospitals NHS Foundation Trust, which runs Russells Hall Hospital, said: "We have made many improvements to our services, one of which is our target for patients to receive surgery for fractured hip in less than 24 hours from admission.
"We have also introduced several measures to improve access to hip fracture surgery including appointing a matron with experience in this field."
But Florence's experience is not unique. A study from the National Confidential Enquiry into Patient Outcome and Death suggests just a third of elderly people undergoing surgery receive good care.
Pain management, nutrition and delays were all highlighted as problems by experts.
The findings prompted the Patients Association to say the problem was a "national disgrace".