An inquest jury has raised 11 concerns over the death of a woman who was not given CPR by staff when she was found unconscious at a specialist care unit.
Joanna Bailey, 36, died of sudden unexpected death in epilepsy, or SUDEP, at Cawston Park, Norfolk in April 2018.
An inquest heard she was not checked for two hours that night, despite 30-minute checks being in her care plan.
The jurors' concerns included staff shortages, training and inaccessible patient information.
They also highlighted issues with governance, emergency equipment and procedures, and communication with the family.
After the hearing, Ms Bailey's father Keith said he was devastated by the catalogue of mistakes, system problems and poor care she received.
Ms Bailey, of Romford, east London, had learning disabilities and health conditions including epilepsy and sleep apnoea, a condition where breathing stops and starts when asleep.
Since October 2016 she had been detained under the Mental Health Act at Cawston Park.
The five-day inquest heard she was required to wear a sleep apnoea mask, known as a continuous positive airway pressure (CPAP) machine at night, to help her sleep, minimise her risk of seizures and the possibility of SUDEP.
The machine's data chip showed she had used the machine 29 times over 209 nights and had not used it since January.
She suffered 60 seizures in her 18 months at Cawston Park, including the evening before her death, but she was not referred to a neurologist.
A registered nurse and five care workers - all first-aid trained - did not attempt resuscitation when she was found unresponsive in her bed on 28 April, the inquest heard.
Paramedics arrived, by which point she had not been breathing for at least 18 minutes, and she was pronounced dead soon after.
Ms Bailey's father, Keith, said: "At no point were we made aware that Joanna wasn't using her CPAP machine.
"Now we are having to come to terms with the loss of our loving, funny and fabulous daughter.
"There were so many missed opportunities to avoid her premature death."
Cawston Park, run by the Jeesal Group, a provider of complex care services within the UK, is currently rated as "requires improvement" by the Care Quality Commission.