A 65-year-old woman who spent almost eight months battling rare infections, died after hospital staff gave her antibiotics through the wrong tube.
A coroner has ruled the mix-up amounted to neglect and contributed to Linda Cantwell's death at Royal Stoke University Hospital.
The mum was initially admitted with a large tumour in her right lung.
Despite a successful operation to rid her of the cancer, she went on to develop the infections and had a series of other procedures to tackle complications.
An inquest heard how the treatment also involved fitting several tubes, including one to help drain Mrs Cantwell's chest and the other to administer medication.
In September last year, a nurse at Royal Stoke accidentally gave her antibiotics through the irrigation tube instead of the Hickman line.
The medication 'spilled over' onto her remaining healthy lung, causing it to become inflamed and infected.
The retired legal secretary died five weeks later – on October 18 – from respiratory failure due to left lung pneumonia and chronic sepsis .
North Staffordshire assistant coroner Sarah Murphy, said: "I do find there was a gross failure to provide basic medical attention."
She said the nurse who used the wrong tube had not read Mrs Cantwell's daily notes beforehand, and she raised a query about the treatment with a peer rather than the nurse in charge.
The inquest was told Mrs Cantwell had initially been seen at Royal Stoke in January 2018 when a scan revealed a six-and-a-half centimetre tumour.
She went ahead with surgery as it was considered the only 'viable' option.
Surgeon Shilajit Ghosh said the procedure went well, but then the patient developed her first bacterial infection.
"It was something really unusual – the ferocity of the infection," he added.
Over the next few months, Mrs Cantwell was in an out of hospital, still battling the rare bugs.
"I have not seen anything like it before. It was defying all logic," Mr Ghosh told the hearing.
But when quizzed about the role the antibiotic incident may have played in her death, he said it would have made a 'more than trivial contribution'.
"The major cause of the death was the sepsis," the surgeon added.
Joanne Hallett, a cardiothoracic nurse at the hospital trust, wrote a 'root cause analysis' report following an investigation.
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