A mother who lost her baby following a mismanaged delivery has spoken of her heartbreak following a 25-year ordeal.

Baby Jennifer Anna McGarry from Kells Road, Crumlin, in Dublin died on 14 February 1992 at 11 weeks old.

"I used to hate the sound of babies crying because I never heard my baby cry," her mother Catherina McGarry said following the conclusion of an inquest into the infant's death at Dublin Coroner's Court.

"Our whole lives changed the day Jennifer Anna died, it felt like part of us died too. After seven miscarriages we were not going to have a family, we were devastated, our world was shattered again," Ms McGarry said.

Her "extraordinarily difficult" 21-hour labour "fell through the stools" of senior clinicians at the Coombe Hospital, the inquest heard.

Consultant Obstetrician and Master of the Coombe at the time of a review of the case in 2012 Professor Chris Fitzpatrick said "alarm bells should have gone off before they did".

The infant died 79 days after an "exceptionally difficult" delivery on 28 November 1991.

The cause of death was bronchial pneumonia due to spinal cord injury due to instrumental delivery with the Neville Barnes forceps.

A Cesarean section would have prevented the tragedy, Dublin Coroner's Court heard.

"This case fell between the stools of a number of senior clinicians. It was exceptional in terms of its duration. The unfortunate findings of this case is that ... standing back and looking at it, alarm bells should have gone off before they did," Prof Fitzpatrick said.

Labour was "allowed to go on for an extraordinary amount of time without intervention," Prof Fitzpatrick said.

He was not directly involved in the supervision of the labour but spoke to a number of staff members as part of the review.

The Neville Barnes forceps was used in a mid-cavity application some 21 hours into labour at a time of extreme maternal exhaustion, the court heard.

"I was screaming in pain because of the pulling. I was told to stop screaming and he started pulling again.

"He wiped his brow and made a comment that he should have done a Cesarean section as this baby is very big. When the baby was eventually delivered I could feel my whole insides being ripped out," Catherine McGarry said in her deposition.

The baby was born with no spontaneous breathing effort and abnormal neurological findings and died on 14 February 1992.

 "Part of the problem was an absence of communication at senior level and failure to make decisive clinical decision," Prof Fitzpatrick said.

The case was reported to the Coroner last September.

Prof Fitzpatrick said he could not explain why the case was not reported to the Coroner at the time but said it should have been.

Representing the McGarry's, Barrister Dr Ciaran Craven asked what lessons had been learned by the infant's loss.

Prof Fitzpatrick replied there was a significant increase in the presence of consultants on the labour ward, a formal ward handover, increased training and direct supervision along with multidisciplinary meetings between care staff.

"It's poor consolation to Stephen and Catherina but it is important to reassure them that this is the case," Prof Fitzpatrick said.

He apologised to the couple for their loss.

Coroner Dr Myra Cullinane returned a verdict of medical misadventure.

Speaking after the inquest, Ms McGarry said she was heartbroken at the loss of her beautiful baby.

"No woman should be treated like I was in the Coombe Hospital that night back in November 1991, I can only describe it as a cowshed birth," she said.