Avon coroner Maria Voisin said the three occasions in which teenager Diana Moore came into contact with Frenchay Hospital in the days leading up to her death resulted in “lost opportunities” to provide her with medical treatment.

In a narrative verdict delivered at the end of the three day inquest, the coroner added that “on the balance of probability” these had contributed to her death.

The hearing was told Miss Moore suffered headaches, nausea, light-headedness and slurred speech for years before an operation in 2005 for a growth on the brain.

She was admitted to Bristol’s Frenchay Hospital on April 18, 2006 with water on the brain, but after four days was sent home. She returned the following Monday but was discharged 24 hours later.

When Diana took a turn for the worse on April 29, an ambulance took her back to Frenchay. But due to a “miscommunication”, an external drain that should have been fitted as soon as Miss Moore arrived was not set up for another two hours.

At 11.50pm on April 29 Miss Moore suffered a seizure from which she never recovered. Consultant Michael Carter admitted he made ‘a bad call’ in sending Diana home.

He added failings on the overstretched ward may have contributed and admitted he did not have the right information to hand when he made the decision.

The NHS Trust for Frenchay Hospital said in a statement that it accepts the coroner’s verdict and it has put in several measures to improve its service.

The statement, from medical director Dr Chris Burton, said: “The trust would like to take this opportunity to repeat our sincere apologies and condolences to the family and friends of Diana Moore.”