Kingston Hospital has been told it must learn the lessons from the tragic case of disabled man Martin Ryan who starved to death after going for 26 days without food.
Martin Ryan, 43, who had Down's Syndrome, was admitted to the hospital after having a stroke, which left him unable to swallow.
Mr Ryan, of Richmond, should have been fitted with a feeding tube, but a catalogue of errors meant he went for nearly four weeks without adequate nutrition.
He died on December 21, 2005, and his case was highlighted in the 2007 report, Death By Indifference, published by learning disability charity Mencap.
The report, which also looks at five other cases of NHS neglect, prompted an enquiry by the Parliamentary and Health Service Ombudsman Ann Abraham, who is due to publish her results later this month.
Richmond Park MP Susan Kramer branded Mr Ryan's death 'devastating' and said lessons must be learnt from the case.
"There are no excuses for the treatment Mr Ryan endured," she said. "Staff simply must raise the alarm any time they have questions about the care of patients. This message must reach every nurse, doctor and carer loud and clear."
Kingston Hospital's chief executive Kate Grimes admitted the hospital had let Mr Ryan down and blamed the tragedy on a "serious breakdown in communication".
"We have met and apologised personally to Mr Ryan's parents and I repeat that apology publicly today," she said. "We feel for Mr Ryan's parents over the loss of their much loved son. We cannot make things better for them, but since 2005 we have made major changes to ensure that another similar tragedy does not occur."
According to Mencap's report, Mr Ryan, whose disability meant he had no speech, was admitted to hospital after suffering a stroke in November 2005.
He had trouble swallowing and was visited by a speech specialist, but his swallow reflex did not return. Because he could not take food or water, he was put on a drip but was unable to tolerate this well and kept pulling it out.
By his second week in hospital he was still unable to eat and was not getting the nutrition he needed.
Staff recorded in their notes that Mr Ryan should remain 'nil by mouth' and that 'alternative feeding methods should be considered'.
Amazingly, no action was taken and by the third week his veins collapsed, which meant doctors could not get the glucose liquid from the drip into his body.
The only option left was to insert a feeding tube into his body but by now he was too weak to undergo the necessary surgery. He died five days later.
The hospital carried out an internal investigation shortly after, which found that there had been a 'multidisciplinary communication failure'.
It found the doctor was under the impression that the nurses had been feeding Martin via a nasal feeding tube, when this was not the case.
Mark Goldring, chief executive of Mencap, called on the ombudsman to condemn the hospital's treatment of Mr Ryan.
"Death By Indifference exposed the horrific deaths of six people with a learning disability who died unnecessarily in NHS care," he said.
"We have fought, and will continue our fight, for justice for their families.The reports have a duty to challenge complacency, where it has been shown to exist within the health service, when treating people with a learning disability and must hold individuals to account for their actions.
"The ombudsman's report needs to make it impossible for people with a learning disability to continue to die unnecessarily at the hands of our NHS."