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The health board has apologised, while the Welsh government said no inquiry is needed
Calls are being made for an inquiry into Welsh NHS care standards and death rates.
It follows allegations that an elderly patient suffered serious neglect at two Abertawe Bro Morgannwg University Health Board hospitals.
Welsh Conservative leader, Andrew RT Davies, wants an inquiry like the Keogh review which has put 11 English NHS trusts in to special measures.
The health board apologised. The Welsh government said no inquiry is needed.
BBC Wales has investigated the case of an elderly woman who was admitted to the Princess of Wales Hospital, Bridgend, and Neath Port Talbot Hospital on three separate occasions between August 2010 and November 2012, when she died.
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End Quote Family member on conversation with nurseWhen I asked her why she was screaming at night, she told me that they hadn't taken her leg off in the two weeks that she'd been there"
When she was first admitted to hospital, the family complained to the health board.
'Barely conscious'BBC Wales has spoken to the family, none of whom wish to be identified.
"It was absolutely appalling," a relative said. "Quite often I'd go in to visit her and I would find that she had been left nil by mouth for several days until she was weak and wasn't able to lift a glass of water to her mouth, she was dehydrated."
Another family member said: "We sat by her bedside until her tongue swelled up and cracked and her lips split open for want of hydration.
"She became delirious at first, then barely conscious, almost coma-like."
The health board said it would conduct a Protection of Vulnerable Adults (Pova) investigation.
However, the board did not contact the family for six months. It apologised and said that lessons had been learnt but no Pova proceedings took place.
When the woman was readmitted in 2012, relatives said they discovered the same problems.
They reported their concerns to social services which is when they learnt that a Pova investigation had not actually taken place.
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End Quote Andrew RT Davies, leader Welsh ConservativesI believe we do need a Keogh inquiry similar to what has gone on in England to address the very real concerns in our hospitals"
Pova proceedings were then used and a number of allegations were proved.
The health board admitted giving unnecessary sedation and failing to administer prescribed medication.
The board also failed to care for the woman's amputated leg.
A family member added: "We explained how her prosthesis could be taken off and showed them the bag of clean amputation socks that we'd taken in for her.
"We also gave them oils to treat her leg to ensure it didn't become inflamed. We explained it all to the staff.
"When I complained that she was having unnecessary sedation, they said it was because she was screaming at night. When I asked her why she was screaming at night, she told me that they hadn't taken her leg off in the two weeks that she'd been there.
"A member of staff pulled back the bedclothes and sat by the side of her bed and took her leg off with me, and took off the urine sodden socks that had been left on her amputation for two weeks and he turned away in disgust, holding the urine sodden socks at arms' length."
Heart attackRecommendations were put in place, but the family said there were similar issues when the woman was admitted to Neath Port Talbot hospital in August 2012.
Then she was transferred to the Princess of Wales Hospital, where she died in November.
The family said they were told by staff that they were stopping her medication as she was dying of pneumonia.
However, a post mortem examination was carried out and the coroner's report said her lungs were free of chronic disease, and that she died of a heart attack.
'Absolutely tragic'Andrew RT Davies, the Welsh Conservatives' leader, told BBC Radio Wales that mortality rates in some district general hospitals in Wales were "spiking at unacceptable levels".
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"I believe we do need a Keogh inquiry similar to what has gone on in England to address the very real concerns in our hospitals so that we can have confidence that health boards, clinicians and families are having their concerns addressed and structures are put in place so we don't get some of the terrible stories that are emanating out of England," he added.
Peter Tyndall, the Public Service Ombudsman for Wales, said: "It's absolutely tragic for the individual and for the family, and I think although there are lots of people who have very good experiences of the NHS in Wales, there are still too many cases of this kind occurring."
He said there had been a 30% increase in complaints about the NHS in Wales in a year.
Tina Donnelly, director of the Royal College of Nursing in Wales, said it was "extremely distressing to listen to a family who are left with those memories".
She added: "My response to this is that this has been an investigation and we need to know what went wrong - it's in the public interest.
"You can not condone poor care. It's just unacceptable."
Abertawe Bro Morgannwg University Health Board said the case is completely unacceptable and apologised for the shortcomings in her care.
It said staff have had training to improve standards and it has asked the family for details to investigate further.
ArrestsThe Welsh government said it is committed to updating the current complaints procedures, and is reviewing the healthcare inspection system.
Health Minister Mark Drakeford has restated the core values of the NHS and set out measures to ensure they are preserved in future.
With these measures in place, the government said it did not see a need for a public inquiry.
In the last two months, South Wales Police arrested two nurses from Princess of Wales Hospital on suspicion of the falsification of records. Both have been suspended from duty.
When asked if there was a connection between these arrests and the patient's case, the health board said it could not comment on police investigations.
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