An inquest has heard a diabetic patient at Stafford Hospital did not get her daily insulin injection until she was found in "a collapsed state".
Gillian Astbury, 66, was admitted to the hospital in April 2007 after breaking her pelvis and arm in a fall.
The hospital was heavily criticised in a report which showed there had been at least 400 more deaths there than would be expected between 2005 and 2008.
A public inquiry into the matter is due to start in mid-October.
Coroner Andrew Haigh told the inquest, in County Buildings, Stafford, that Mrs Astbury, of Hednesford, needed a daily injection normally given in the morning.
While in hospital she was given the injection on 9 April, but was not given any more until she was found in a collapsed state on 10 April.
Mrs Astbury died, following treatment, on 11 April.
Her cause of death was given as the result off a diabetic coma following insulin deficiency and a urinary tract infection.
The inquest jury heard that some of the nursing staff were not informed that Mrs Astbury was diabetic and some said they were too busy to check patient notes at the foot of her bed.
On the morning of 10 April, her blood sugar levels were found to be "very high", but no medication was given and her blood sugar was not monitored.
Senior staff nurse Patricia King said she had not been told Mrs Astbury was diabetic and assumed another nurse was taking care of her medication.
"I'm very, very sorry, I really do wish I'd had time to look at the handover sheets and been able to have done something sooner," she told the inquest.
She said she was "shocked" when she started work at the hospital, saying it was like going back 20 years on her ward.
Staff "muddled through" in poor conditions, Ms King said, with no office or nursing station and a shortage of nurses and support workers.
"Day after day, week after week, months after month, you are going home late because you are trying to do everything you can," she said.
"This was an appalling case but equally, the conditions we were working in were appalling too."
Staff nurse Brenda Laverty told the inquest that handovers between shifts were not given at the patients bedsides, making it difficult to remember information about individuals.
She said she may have been told about Mrs Astbury's condition, but may have forgotten.
A support worker, Michelle Appleton, said she knew Mrs Astbury was diabetic but did not mention it to the nurses on the ward because she assumed they knew.
Police investigated Mrs Astbury's death but the Crown Prosecution Service said there was insufficient evidence to bring charges.
Anthony Sumara, the hospital's chief executive, although he was not in post at the time of Mrs Astbury's death, has apologised for her care.
"You can't defend something as basic as not giving a known diabetic their insulin," he said.
The inquest continues.