A female Royal Navy officer with a promising career before her was left to die on the floor of her cabin because colleagues thought she was drunk.

An inquest jury blamed a series of mistakes yesterday for the death of 29-year-old Lieutenant Emma Douglas in a diabetic coma when her life could easily have been saved.

The inquest heard that four days before her death in October 2004, Lt Douglas was seen by a navy doctor, Surgeon Commander Marcus Evershed, who failed to spot the symptoms of Type 1 diabetes. Lt Douglas had lost four stone in the two months before her death and was suffering from oral thrush and vomiting. The doctor advised her to rest and return if the symptoms persisted but failed to suggest a urine test for diabetes.

Later a midshipman who saw Lt Douglas lying unconscious, partially clothed and “gurgling” on the floor of her cabin on board the destroyer HMS Cornwall, simply closed the door, assuming that she was sleeping off a hangover. Petty Officer Gary Shuttlewood reported it to Warrant Officer David Carter, the officer of the day, but he took no action.

The jury at the Plymouth inquest returned a narrative verdict in which they said Lt Douglas died from diabetic ketoacidosis but criticised her care in the days before she died, calling the doctor’s advice “inadequate” and the officers’ reactions “inappropriate”.

“The diagnosis of oral thrush in itself must lead to further investigation as there will be an underlying problem. There was no investigation to establish the underlying cause.

“The advice to her to return if she was not better provided a safety net but in the light of the diagnosis it seems inadequate.”

The jury said her fellow officer had failed to follow proper procedures when she was found on the cabin floor. They ruled: “If the correct procedures were followed it would have established if Emma was just asleep or if alcohol or illness was involved.

“Given the unusualness of her state of undress and the fact she was on the floor with noisy breathing this should have triggered a greater response. The situation was significant enough to have been verbally reported to the officer of the day and this should have been taken seriously and entered in the incident log and investigated.

“The only action taken was to return and close the cabin door. This action was inappropriate as it conveyed to subsequent personnel she did not wish to be disturbed.”

Ian Arrow, the coroner, is to send the jury’s findings to the General Medical Council and the Navy so they can consider disciplinary action against those involved.

After the hearing Lt Douglas’s mother, Cynthia Douglas, said the family would be pursuing legal action against the Ministry of Defence. She said: “Sadly, we shall always believe she was badly let down by her naval colleagues. Despite the criminal investigation and the naval board of inquiry no one has accepted any responsibility or been held in any way accountable for Emma’s death. This is something our family have found very disappointing.”

Lt Douglas, from Huntly, Aberdeenshire, was a former public schoolgirl, a keen fencer and engineering graduate. She was one of the first women to become an engineering officer. She went to sea in the footsteps of her father, Christopher, a merchant seaman who drowned when his ship sank in 1989.

Her mother is angry that the jury was not allowed to consider a verdict of unlawful killing. She said: “Emma was a vivacious young woman who loved life to the full. She was a truly wonderful human being. We all miss her terribly and think of her every day.

“We hope the findings of the jury will enable the Royal Navy to review its procedures to ensure no one else loses their life in similar circumstances.”

A spokesman for the Navy said that lessons had already been learnt and procedures tightened.

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