Black Country coroner Zafar Siddique said staff at Russells Hall Hospital in Dudley could have done more to ease the suffering of Medina Jones, who had been diagnosed with the rare condition calciphylaxis, which affects patients with kidney disease and results in chronic non-healing wounds.
An inquest at Smethwick Council House heard a series of concerns raised by Anna Diamond, the lawyer representing Mrs Jones' family, that her wounds had not been dressed properly, while a tissue viability nurse had not been involved early enough in her care.
Tissue viability is a specialism in wound prevention and management.
Other issues included the fact she was moved between wards and there appeared to be a lack of communication between departments.
Mrs Jones, 42, from Brierley Hill, had been diagnosed with renal impairment in 2006.
Three years later, part of her stomach was removed and she had liposuction, while in March 2012 she was diagnosed with calciphylaxis, which has an extremely poor prognosis and is usually fatal.
On December 19, 2012, she was taken to A&E with extreme abdominal pain and on December 25, emergency surgery was performed on her small bowel, which resulted in her having a stoma, which is a surgically created opening in the abdomen allowing stools or urine to leave the body.
However, there were problems with the stoma as the edge of the wound was not healing, while a calciphylaxis wound that had initially shrunk, was found to be getting larger.
In February, she fell on her stoma bag, which resulted in a possible fracture of her left ankle and continued to experience problems with her stoma, which led to the wound breaking down.
Her dressing was changed on April 3, but she died the following day.
The inquest heard statements about Mrs Jones treatment from a number of medical staff from the Dudley Group NHS Foundation Trust.
Julie Paine, head of surgery with Dudley Group, said a number of improvements to procedure had been introduced in the wake of Mrs Jones' death, including wounds being better assessed and documented at each dressing change, while the number of nurses trained in tissue viability has increased from two to three. Other changes included improvements in the administration of analgesics to relieve pain and the discharge procedure for patients.
Mr Siddique said Mrs Jones' death had been due to sepsis in the abdomen wall caused by gangreneous stools, which were the result of chronic kidney disease and calciphylaxis.
He added: "Mrs Jones presented with a complex medical condition called calciphylaxis. The prognosis is extremely poor and described as life limiting. Despite surgical intervention, her condition deteriorated rapidly and she died. Failures of wound care and pain management led to the distress for the patient and her family."
However, he said there was not enough evidence to support a verdict of neglect by the hospital staff.
Following the inquest, Beverley Parkes, Mrs Jones' sister, said: "We are very upset by her treatment in the hospital, which caused her to have pain and suffering. We just hope that lessons have been learned."