A coroner has criticised Cypriot medics after a young Gloucester woman died when doctors made an "entirely avoidable" mistake and failed to spot her ectopic pregnancy.
Kalisha Gordon, 21, was on a working holiday in the Mediterranean party resort of Ayia Napa, in Cyprus, when nurses revealed she was pregnant with her first child.
But just days later Kalisha - who had planned to fly home to tell her parents the good news - began to experience severe stomach cramps and vomiting.
She was left "screaming in pain" and was rushed to hospital but doctors failed to spot all the hallmark signs of an ectopic pregnancy - where a fertilised egg implants itself outside the womb.
Instead they told her the baby was fine and gave her painkillers - but she was found unconscious on the floor of her hospital room and tragically died six hours later.
Today Coroner Katy Skerrett issued a damning verdict on the medical attention she received in Cyprus.
She said: "At no stage was the ectopic pregnancy diagnosed and at no stage was she treated for it.
"The first stage they were aware of the ectopic pregnancy was when the post mortem was carried out.
"There was a failure to diagnose and a failure to treat an ectopic pregnancy by medical authorities approached by Kalisha.
"This was a tragic accident that was entirely avoidable."
Gloucester Coroner's Court heard Kalisha had moved to Cyprus in June 2008 to hand out flyers in Aiya Napa.
On July 22 she went to a local doctor's surgery after taking a positive pregnancy test, where she was told to return after a few days for an ultrasound.
The scan, on July 26, revealed she was seven weeks pregnant and Dr Petros Afxentiou told the mum-to-be everything was healthy.
Kalisha, of Tuffley, quickly booked tickets to return home to tell her parents she was expecting her first child with boyfriend of two years Daniel Douglas.
But the day before the flight, July 29, the "bright and bubbly" young woman fell ill with severe vomiting, chest pain and began to faint regularly.
In a statement read to the inquest Rachel Cotter, a friend with Kalisha at the time, said: "At around 5pm Kalisha suddenly said she started to feel cramps and began to scream in pain.
"We drove her straight to the doctors, on the way she vomited at least five times.
"She was screaming in pain in the surgery, she kept asking if the baby was ok.
"The doctor gave her an injection and telephoned for a taxi which took her to hospital."
Kalisha was immediately admitted to a ward in the hospital in Paralimni, Cyprus, where nurses put her on a drip to give her painkillers.
The inquest heard it took three hours until an ultrasound was carried out, at 9.15pm, where Dr Afxentiou once more said the baby was fine.
Kalisha continued to faint throughout the evening and told nurses she as feeling dizzy with severe stomach pain, but they continued to give her painkillers.
A ward worker eventually found her unconscious on the floor of her room at 11pm where she was rushed to the intensive care unit, but sadly died at 2.30am on July 30.
Her devastated family were initially told Kalisha had died of a heart attack and the ectopic pregnancy was only revealed when the post mortem was carried out days later.
The court was told that an inquest was carried out in Cyrpus in 2012 where expert witnesses found a number of failings and breaches of care had occurred.
Adam Magos, a consultant gynaecologist at the Royal Free Hospital, London, said he found a number of errors in the way the ultrasounds had been taken and the care given to Kalisha.
In a statement read to the court he said: "She had several symptoms and signs which suggested for a possible report of ectopic pregnancy.
"She was known to be in the early stages of pregnancy, she was complaining of abdominal pain and had fainted for no obvious reason a number of times."
He said the ultrasound scan took place at an "inappropriate angle or corner" which allowed a normal pregnancy to be diagnosed.
"This must have been incorrect, no fetal activity was seen on the scan, the doctor identified it in error," he told the inquest.
"Steps should have been taken to determine the cause of the reported fainting."
The Cypriot inquest found there had been "serious variations in relation to the understanding and description of events between doctors, Kalisha and nursing staff".
They found it was unclear whether information had been passed on to staff.
Coroner Skerrett recorded a narrative conclusion and said she had taken on board all that had been revealed in the previous inquest.
Speaking after the inquest Kalisha's father Lloyd George said it had taken the family six years to finally get the truth about their daughter's death.
He said: "The doctors messed up six years ago and we have had to fight for the answers.
"We had to battle hard for the first three years just to get an inquest into her death.
"Our aim is to stop anything like this happening again, the Cypriot authorities aren't listening to us.
"Nothing will bring Kalisha back but if we can stop any family going through this like us we will
"There were serious failings, she was in hospital for six hours and no one diagnosed it. It needs to be seriously looked at."
He added the family had approached the European Court of Human Rights with a specially hired Cypriot lawyer to get justice for Kalisha.