Instead of connecting the symptoms to organ rejection, the staff at the hospital misdiagnosed Hannah Pudsey with diabetic ketoacidosis, an investigation into her death revealed.
24-year-old Hannah Pudsey died after she suffered organ rejection following a heart transplant she underwent as a child.
She had become an inspiration to many thousands of people to sign up as potential organ donors after she was given a heart transplant at 13.
She breathed her last on February 1st 2012.
Miss Pudsey's parents, Ross and David, felt that their daughter should have been seen by a cardiologist in the high dependency unit (HDU). Inexperienced medical staff had seen her and was unable to identify that she was a victim of heart failure.
Both the staff nurse and ward sister had no experience of treating a heart transplant patient.
Dr Jane Patmore, a consultant physician at the hospital, said, "The diagnosis was, at best, only part of the issue. My concern is that we set off down a pathway. If we had been able to identify there were more issues, we would have taken a different path and that might have been to the HDU."
She said the cause of death should be recorded as metabolic acidosis, which occurs when the body produces too much acid or when the kidneys are not removing enough acid, along with heart rejection.