An Oxford lecturer could still be alive if doctors at a hospital had checked medical records and liaised with other staff, an inquest heard.

A review and overhaul of care procedures is being carried out by Oxford Radcliffe Hospitals NHS Trust following the death of Dr Clara Cooper, am Italian teacher from Polstead Road, Oxford.

Her family's "serious concerns" about the standard of care she received at the John Radcliffe Hospital, Oxford, were confirmed when Oxfordshire's deputy coroner Dorothy Flood recorded a verdict of misadventure at an inquest into her death.

Dr Cooper, 56, was taken to the hospital by ambulance at about 3am on May 4 after suffering severe breathlessness. She had previously been vomiting and had felt weak for a few days before.

Three blood tests were taken throughout the day.

Results from the first, taken during the night, revealed her body had dangerously low calcium levels.

Honorary consultant physician Dr Sebastian Fairweather said it was normal procedure for the hospital's laboratory to contact the relevant doctor or ward if levels were lower than standard.

Dr Cooper's case was passed on to another doctor, who saw the results and noted: "This was the lowest such result I had seen". Thinking there may have been a mistake, he ordered a repeat blood test.

Dr Cooper's case was passed on to another team of doctors swapping from the night to day shift.

The doctor passed on assessment notes verbally and another blood test was carried out.

The laboratory results were in by early afternoon and again showed low calcium levels, but Dr Fairweather said there was no record of a warning in the ward log book.

Dr Cooper was diagnosed as having a chest infection or possibly pneumonia. Her husband Prof Richard Cooper said she was "looking better" by 2pm.

But just after 7pm she began experiencing breathing difficulties and went into cardiac arrest. A medical team tried to resuscitate her, but she died shortly before 8pm.

The cause of death was given as a pulmonary embolism.

But a post mortem by pathologist Ian Buley revealed no signs of that or pneumonia.

Instead, he said the cause was hypocalcemia -- low calcium levels.

Dr Fairweather agreed there were gaps in what had happened to blood test results from the laboratory.

When asked by Mrs Flood what would have happened if the low levels had been spotted, he said: "She would have been given intravenous calcium. The effect would have been that she would not have arrested.

Mrs Flood said she would have ordered the hospital to carry out a review, but it was already doing so.