A young mother died six hours after her baby was born after 23 doctors mistakenly mistook a brain stem tumour for an ear infection.
While she was pregnant, Rosie Kremer, 24, suffered two months of agony and lost two stone.
She was violently sick, slurred her speech and started to lose coordination of her limbs. But despite her pleas for help, doctors insisted her pain was being caused by an inner ear infection called labyrinthitis.
Rosie, who lived in Penrith, Cumbria, spent the last five weeks of her life in bed, unable to sit up or use her hands. A CT scan carried out after brain death revealed a very large brain stem tumour on the right side.
Her mum Lesley said: "I honestly didn't know what was the matter, but everyone seemed convinced she was just having a bad pregnancy.
"It didn't have to kill her. If somebody had spotted it she would have been fine, she would have recovered."
Rosie was declared brain dead at 10.30am on 29 May 2012. Less than six hours earlier, at 4.30am, doctors delivered her baby boy, who she'd already named Bobby Peter, at 29 weeks. He weighed 2lb 14oz.
Her grieving mum Lesley, 57, said: "The care she received was appalling. There was no joined up care. She was sent home twice from hospital.
"There was a note somewhere about cranial pressure, but despite all her symptoms nobody ever diagnosed a tumour. They weren't looking at the overall picture.
"Towards the end she was crying in pain and begging to die. "Even then nobody was prepared to believe it was anything other than labyrithitis.
"I just kept asking people to help her. She became a zombie, she said the pain was so bad she wanted to die."
Lesley is now bringing up little Bobby as his legal guardian. Bobby's dad had split from Rosie before he was born but sees him once a week.
Lesley, said she later learned that even an hour before her death Rosie could have made a full recovery if her condition had been correctly diagnosed and the fluid had been drained from her brain.
She is now suing North Cumbria University Hospitals NHS Trust, which manages Cumberland Hospital, in Carlisle. The Trust said it could not comment on individual cases.
Lesley, a part-time teacher, has spoken of her daughter's death to promote organ donation as Rosie's donated organs helped save eight lives after her death.
In her honour Lesley is to attend a ceremony at St James' Palace, London, to collect The Order of St John United Kingdom Award for Organ Donation.
A spokesman for the Order of St John, the charity that created the new accolade, alongside NHS Blood and Transport, said: "This award has been created for two purposes - to say thank-you to families whose loved ones have already donated, and to inspire more people to follow in their footsteps and sign up to be an organ donor.
"Around three people die every day due to the shortage of organs, and there are 10,000 people in the UK in need of a transplant."
Lesley added: "Organs get wasted because families are obviously shell-shocked after a death.
"We had already made up our minds so it was quicker and we kept Rosie on life support so that the nurses had time to check the organs and get them to the right people.
"It just takes five minutes to sign up and it is so, so important. You have to think, 'what if I needed a lung, or a heart or something?'"
• To join the NHS organ donor register, visit www.organdonation.nhs.uk or call 0300 123 2323, or text SAVE 62323.