Mother-of-three Judith Laing, 65, passed away at Inverclyde Royal Infirmary, in Greenock, almost two months after a crucial delay in carrying out surgery for a strangulated hernia – the same condition suffered by BBC Scotland newsreader Jackie Bird.
Three GPs examined Mrs Laing after she began vomiting at her home in Port Glasgow, but failed to diagnose the condition.
Four days later she was admitted to hospital, where a medical team again failed to spot what was wrong.
Mrs Laing, a cleaning supervisor, finally underwent surgery nine days after taking ill, but died seven weeks later from a post-operative infection.
Now a sheriff has blamed the lack of an early diagnosis for the need to operate and said her life could have been saved.
In a ruling following a fatal accident inquiry into the tragedy, Sheriff Derek Hamilton said: "There is no doubt this is an extremely tragic case.
"Had Mrs Laing's symptoms been correctly interpreted at an earlier stage, it is unlikely she would have required such extensive surgery.
"It was explained that the longer a patient had a strangulated femoral hernia the more likely it was the organ would be non-viable, and therefore an operation would be required.
"Mrs Laing had nine days of her bowel not functioning properly before she underwent surgery. She had dilation of the small loops and therefore required a longer post-operative recovery.
"Clearly, Mrs Laing's death could have been avoided if her symptoms had been correctly diagnosed earlier."
Dr Graham Currie, the on-call consultant when Mrs Laing was first admitted, was criticised by the sheriff following the inquiry at Greenock Sheriff Court. Mrs Laing's GP, Dr Maureen Smith, had phoned Dr Currie to convey her concerns prior to her admission to hospital but he failed to read the referral report.
The inquiry heard he also failed to examine the patient during the four days she was on the ward and signed her medical records without properly reading them.
Sheriff Hamilton added: "Dr Currie accepted it was unusual for a GP to telephone him in advance of him receiving a patient. Clearly Dr Smith was unsure of the cause of Mrs Laing's symptoms and wished them further investigated.
"That, I would have thought, would have been good reason for a senior doctor to have examined Mrs Laing at an early stage.
"Had Dr Currie reviewed the admission records and examined Mrs Laing, he would have been aware of the presence of a ... number of symptoms which indicated a possible bowel obstruction.
"I have concerns that while Mrs Laing was admitted to Inverclyde Royal Hospital on December 4, 2008, she was not fully examined by a senior doctor over the period to December 8, 2008, and that only once a surgical review was called for was she examined by a senior physician.
"It seems that effectively no senior doctor took charge of Mrs Laing's care on her admission. Dr Currie at no time properly examined her."
Sheriff Hamilton concluded there was no effective system on the ward to identify the doctor with overall charge of a patient and called on the hospital to review its procedures.
Mrs Laing's widower, Alastair, 71, said: "In my opinion the reason Judy died was down to neglect.
"She went to the hospital and never came home.
"The last four years have been extremely hard and I really miss her. I agree with the report and I hope changes will be made so that no one else will have to go through the same thing."
Bird, 50, had emergency surgery for a rare bowel condition before Christmas.
Doctors had said she was three hours from death after being rushed to hospital from her home with agonising stomach pains. She has since returned to TV screens.