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Tomorrow a coroner will give her verdict over a grandmother's death from thirst after being prescribed powerful diuretics.
Edna Thompson was rushed to hospital in September last year with a suspected malignant glaucoma in her right eye.
Just over a week later she suffered renal failure and died - despite family repeatedly saying she was becoming dehydrated.
Today, on the second day of an inquest into the 85-year-old's death, the court heard how ophthalmologist Dr Maria Dimitri was unaware the former librarian from Harrietsham had been given an ongoing prescription of mannitol when she saw her at an emergency eye clinic four days before her death.
Mannitol is a powerful drug that has the effect of ridding the body of unneeded water and salt through urine. It was given to Mrs Thompson to reduce the pressure in her eye which was causing her intense pain.
The coroner heard that it is very unusual to be given to patients for more than two occasions.
New evidence also emerged showing regular monitoring of Mrs Thompson's fluid levels and nutrition was not put in place until shortly before her death early in the morning of September 23.
Senior coroner Patricia Harding said: "What is clear from the charts is that Mrs Thompson was not placed on fluid balance monitoring until at the earliest on the 21st of September."
Dr Dimitri told the court there was no indication of the diuretic in the written records she had access to and if it had she would raised this with her colleagues and called for a daily review.
When asked why she had not reviewed the drug chart, she said: "My assumption is I read the written record of what her drugs were and went on that basis, rather than looking at the drug chart."
Maidstone and Tunbridge Wells NHS Trust’s own investigation found a catalogue of errors in failing to prevent and act on the mother-of-three’s dehydration, including that she was given drugs known to cause thirst longer than she should have been.
Despite health chiefs making a grovelling apology, Mrs Thompson's relatives have previously said they will not have closure until the inquest is concluded into the sequence of events leading up to her death.
They allege that agency nurse Bindya Sunu reviewed to provide her with water out of fear she would wet the bed. Ms Sunu strongly denies this.
The coroner will give her verdict tomorrow at 10.30pm. She is expected to reach a narrative verdict and will not issue any recommendations on how the hospital can improve.