Leeds Teaching Hospitals NHS Trust was issued with an official note - known as Regulation 28 Report to Prevent Future Deaths - after an inquest into the death of Theresa Button.
The 65-year-old had the transplant in August 2017 and remained in hospital for 15 weeks. She developed pneumonia and died on December 7 that year.
The report said: “The deceased’s family contended that her death was contributed to by the deficiencies in nursing care which arose due to insufficient nursing staff being available at certain times on Ward J83 at St James’s University Hospital.”
The conclusion of the inquest last September was natural causes, the report said. Senior coroner Kevin McLoughlin said there was evidence that staff on the ward were too busy to fully implement treatment plans.
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Nursing records were not always kept up to date and staff did not have time to explain treatment decisions. The report said: “A family member witnessed her food being left on her tray whilst she was laid flat and hence unable to access it, with the result that it went cold and she did not eat, despite the concern relating to her nutritional condition.”
Dr Yvette Oade, Acting Chief Executive at Leeds Teaching Hospitals, said: “We have addressed the matters that the coroner raised in his report to improve the care that we provide.
"Staffing levels on all our ward areas are reviewed daily in accordance with safe staffing requirements together with the numbers and individual needs of our patients. We have an agreed, well designed and tested escalation process to provide additional staffing when required.
"The nursing needs, clinical treatment and support requirements of our patients are reviewed on a daily basis alongside any nutritional needs.
"Record keeping around nutrition and hydration has improved on the ward and the results from a recent audit demonstrate a high level of compliance across key areas.”