A sexual health organisation is reviewing its procedures after the death of a 15-year-old girl who had an abortion at one of its clinics.
Alesha Thomas was allowed to leave the Marie Stopes International clinic in Leeds in July 2007 without antibiotics.
Five days later the Huddersfield teenager died from a heart attack due to the infection toxic shock syndrome.
Antibiotics would probably have saved her, said coroner Roger Whittaker. He urged the clinic to change its systems.
The inquest in Huddersfield heard how the gynaecologist who performed the abortion issued an electronic prescription for an antibiotic to be given to Alesha.
But she had already left the building and she was never given the prescription.
As Alesha's condition worsened her mother, Rose Bent, called a hotline reporting stomach cramps and bleeding but it appeared her notes were not consulted and nobody noticed the antibiotic had not been prescribed, the inquest was told.
She died on the way to hospital on 11 July.
Mr Whittaker, the coroner for West Yorkshire (Western), recorded a narrative verdict and said he would write to Marie Stopes International.
He said he thought there should have been a review of the case after the gynaecologist had left the clinic and he hoped the organisation would put different systems in place to stop patients leaving without their medication.
In a statement after the inquest, Marie Stopes International said: "All the staff at Marie Stopes International were deeply saddened to learn of Alesha's tragic death.
"We wish to extend our sympathies to Alesha's family and recognise that this has inevitably been a difficult and distressing process for them, and for all involved.
"Marie Stopes International is grateful to the coroner for giving Alesha's family an opportunity to obtain answers to their questions.
"Our first concern is always the support and care of our clients and we aim to ensure that they receive the highest possible standards of advice, treatment and aftercare. We will look closely at the coroner's comments and take further steps, as appropriate, to address any areas of concern that have been identified."