It was only the determination of Laura’s parents that her death should not be in vain that has led to the Coroner demanding the hospital trust examine its procedures for carrying out medical observations and make sure that the appropriate equipment is available to patients.

Because Laura’s death, nearly three years ago, was from natural causes, Professor Paul Marks did not immediately call for an inquest but Mr and Mrs Garner made the decision to publicise the results of the trust’s internal investigation into their daughter’s death, which revealed a catalogue of failures in her care.

They also shared the Serious Incident Report with Prof Marks who wrote at the end of 2010 to say it meant an inquest would be held.

He employed an expert, Professor Michael McMahon, whose conclusion that there were missed chances to save Laura’s life formed the basis of the narrative verdict.

Mr and Mrs Garner said they were grateful for the work of Prof Marks and Prof McMahon, which had helped improve their understanding of the circumstances and causes of Laura’s death.

“It has been a long road but I would say to anyone who may find themselves in the same situation ‘don’t give up’,” said Mrs Garner. “I could not accept that someone who had been treated so badly could be a death by natural causes and that is what they have decided – that Laura could still have been here.

“Even though that was really hard to hear, it has helped us come to terms with what happened.”