A man with severe learning difficulties died from natural causes contributed to by neglect at a Swansea hospital, a coroner has ruled.
An inquest in the city heard that Paul Ridd's nursing care at Morriston Hospital was substantially below the expected standard.
Mr Ridd, 53, from Baglan, near Port Talbot, died after an operation on his bowel in January 2009.
Abertawe Bo Morgannwg Health Board said its care quality had since improved.
Mr Ridd, who was described by his family as a gentle giant, could not communicate beyond a few words.
He died from respiratory problems after being transferred from intensive care to a general ward. The inquest was told that there were omissions in a number of areas in his care.
Linda Bevan, head of nursing for the surgical unit, told the hearing that staffing levels among nurses on Mr Ridd's ward had not been high enough, but they had since improved.
She also said his nursing notes did not follow set guidelines and were not good enough.
She conceded that suction to Mr Ridd's lungs, which doctors had said should have happened every two to four hours, occurred only three times in total during a stay of nearly three days in the ward.
She added that if he had been in the hospital now, his care would have been immensely different.
At the end of the two-day hearing, Mr Ridd's sister Jane Nicholls wept as Swansea coroner Philip Rogers ruled that the hospital's neglect had contributed to his death.
He told the coroner's court that there had been catalogue of errors in Mr Ridd's treatment, a gross failure to provide adequate medical care and a clear connection in the way he was treated and the cause of his death.
'Third World country'
Following the inquest, Mr Ridd's brother Jonathan said he was pleased with the verdict and felt the family had been given "some justice".
His sister said they hoped the case would lead to "major change" and that what they had been through would not happen to anybody else.
"I'm satisfied with the outcome [of the inquest] because we have been listened to," she said. "I'm still heartbroken because he actually died from neglect and there was a chance he could still be here."
The family is now working with the hospital to provide better training for staff to meet the needs of disabled people.
The health board offered its "sincere condolences and apologies" to Mr Ridd's family.
"We are truly sorry that whilst he was a patient on one of our wards, Mr Ridd received care which fell well below acceptable standards," it said.
"Following this tragic event a thorough investigation was carried out and improvement actions identified. We have worked hard to address the shortcomings identified and have taken action to improve the quality of care we provide across the health board.
"We appreciate that these improvements in care can be of little comfort to the family of Mr Ridd. The health board would like to acknowledge that the concerns raised in this case have improved care for others."
In 2011, the public services ombudsman for Wales said in a report into concerns surrounding his death that Mr Ridd's nursing care was "abject" and "dire".