And the man in charge of the hospital's intensive care unit believes she might have survived if staff had done their jobs better.

Kristy Pemberton, of Bishops Itchington, was admitted to the accident and emergency department four times between 10am on September 25, and 4am the following day, complaining of shortness of breath.

She was discharged three times and died in intensive care on September 26.

Her father told the inquest at Leamington town hall on Tuesday that his daughter had been unwell for a week before she died and kept vomiting when she tried to eat and drink.

She was admitted to casualty twice and sent home.

Miss Pemberton was admitted for a third time by ambulance at 6.22pm after collapsing at home. She was treated and a referral to a community psychiatric nurse was made.

She was admitted again by ambulance at 4.48am the following morning after suffering a cardiac arrest at home. Her parents gave her resuscitation while waiting for paramedics to arrive.

Miss Pemberton was given a chest x-ray at 6.11am and suffered a further cardiac arrest. Dr Aulakh explained resuscitation was difficult and after a discussion with the family, attempts were abandoned.

Dr Aulakh believes the patient might have lived if she had been treated sooner. He said: "It is my view, all be it hindsight that at her third admission she should have been looked at more thoroughly and there is a chance she would have been treated further. It is impossible to say she would have survived.

"But if somebody had seen the x-ray ten hours earlier I would have to think that she would have been given antibiotics and probably been admitted. That may have meant she would have survived but I can't say whether she would have."

Warwick Hospital pathologist Dr Scott Sanders conducted the post mortem. He found the cause of death to be 'shock lung' - a breathing failure - cardiac arrhythmia and pneumonia. Liver disease was stated as a factor which may have indirectly contributed to death.

Warwick Hospital accident and emergency doctor Rose Rau was not at the inquest. The coroner adjourned proceedings to arrange for the witness to be summoned.