 Mary Niersmans' legs were broken for four days before she was treated |
The families of two women, who died after failures at a hospital already being questioned about patient safety, say their deaths were needless. Mary Niersmans, 81, and Peggy Cotter, 80, both died after 'unacceptable care' at Cardiff's Whitchurch Hospital.
Mrs Niersmans suffered two broken legs which were undiagnosed for four days.
An official report, leaked to the BBC, had queried patient safety just months before the deaths. The hospital said all its improvements would take time.
The March 2004 report had revealed that staff felt lessons had not been learnt from earlier serious incidents involving elderly mentally ill patients. It prompted Cardiff and Vale NHS Trust to launch an action plan.
 |  If they had used a hoist, she would still be alive today  |
But the BBC has discovered that just months after the report was published, Mrs Niersmans, from Llanishen in Cardiff, suffered two broken legs after being taken to the toilet by two male care assistants.
Despite complaining of pain, and a doctor recommending she should be X-rayed, Whitchurch Hospital staff did not send her for diagnosis for four days. By then she had developed breathing difficulties.
She died at the University Hospital of Wales two weeks later.
Her family complained to the hospital that staff had failed to use a hoist to lift Mrs Niersmans, who had been unable to walk for six years.
 Peggy Cotter suffered 'aggressive behaviour' from some staff |
"If they had used a hoist, she would still be alive today," said her daughter, Irene Nelmes.
An external investigation concluded there had been "serious errors". The hospital trust told the BBC it could not comment on individual cases.
Within months of Mrs Niersmans' death, Whitchurch Hospital was again admitting failures in its care on the same ward for elderly mentally ill patients.
The family of Peggy Cotter from Rumney in Cardiff complained to the hospital after she was admitted in October 2004.
They felt staff neglected her after they had complained about care standards and said there was a dramatic deterioration in her condition which hastened her death at the hospital in November.
'A general impression of ineptitude'
Her son Allan said: "We complained about it (her treatment) and it wasn't liked. My biggest regret is leaving her in that hospital."
A hospital investigation agreed with many of the family's complaints, although it said Mrs Cotter's cancer, which was undiagnosed at the time, would also have contributed to her decline.
Among the hospital's findings were:
Nursing care below an acceptable standard, and evidence of neglect.
A lack of management...which led to poor communication, disorganised working practices and a general impression of ineptitude. Inappropriate and aggressive behaviour by staff towards Mrs Cotter and her family. The hospital told the family how it had brought in improvements as a result of the investigation, including disciplinary procedures, appointing a new ward manager and extra staff training.
In a statement to the BBC, the trust said the care and treatment of patients was its number one priority and the findings of the March 2004 report were being acted on.
It added: "Whilst the trust is taking action as quickly as is possible, within the resources at its disposal, the full implementation of all the action plan's aims will only be achieved over time".
The assembly government said it was monitoring progress of the trust's action plan, and could not comment on indvidual cases.
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