A verdict of medical misadventure has been returned at the inquest into the death of a woman at Galway University Hospital in June of last year.
Galway Coroner's Court heard that Kathleen Kilgallon, from Swinford in Co Mayo, died from septic shock following on from Toxic Epidermal Necrolysis, a serious skin infection.
The 64-year-old had been admitted to hospital in February for cancer treatment.
That progressed well but she contracted an initial infection during her stay on St Patrick's Ward and her condition deteriorated over a number of weeks.
During evidence earlier today, Mrs Kilgallon's husband, Thomas, told the inquest that he sought a doctor for his wife on the morning of 9 June 2012 because she was feeling very unwell.
She had developed sores on her mouth as a result of the infection and had told Mr Kilgallon that it felt as "if there were a thousand pieces of broken glass in it".
He said his wife waited six or seven hours before being seen by a doctor.
During that time, a nurse advised Mr Kilgallon to go to a pharmacy to buy Bonjela, as the hospital pharmacy was closed at the weekend.
Coroner Dr Ciaran McLoughlin asked Dr Michael O'Leary, a consultant who treated Mrs Kilgallon, if this was possible.
Dr O'Leary told the inquest that it was and it was the unfortunate situation that there are "multiple specialities not present in the hospital at weekends".
The inquest subsequently heard from Dr Mark Regan who said there were keys available for drugs that nurses could access in the event that they were needed. Bonjela would is not a prescribed product.
Mrs Kilgallon was moved to the intensive care unit on 13 June and died on the evening of 19 June.
Dr McLoughlin returned his verdict after a day of hearings at Galway Courthouse.
Mrs Kilgallon's family have welcomed the verdict and said say they are hopeful the HSE, and Galway University Hospital in particular, will act on the lessons that should be learned from today's proceedings.
The Kilgallon family solicitor said they were greatly upset at Kathleen's passing, but they did not hold grievances against any individual as a result of her death.
Earlier, Dr McLoughlin said it is "disgraceful" that two hospital consultants were not present to hear testimony at the inquest into the death of a woman at Galway University Hospital in June 2012.
The coroner dismissed suggestions from a lawyer for the hospital that the doctors did not know the inquest was beginning at midday.
He said he had "emphatically communicated" to them that he was not prepared to adjourn the proceedings today to facilitate them.
Dr McLoughlin was also critical of the hospital's decision to supply medical notes relating to Mrs Kilgannon's care on a CD-Rom.
He said a hard copy of the records should have been provided to the family and he instructed the hospital to provide documentation in this fashion in future.
Mrs Kilgannon's husband said he wanted answers from the Coroner's Court to set his mind at ease.
He said his family wanted to ensure that the hospital learned lessons from what had happened to his wife.
His experience in parts of the hospital did not lead him to believe that it was a centre of excellence in every way, he said.
Her son, Thomas Kilgannon Jnr, also gave evidence.
He said his mother's initial treatment had gone well and that until 9 May 2012 she was recovering well.
The inquest heard that his mother was a nurse who had chosen that profession because she was a "natural carer".
He said the nursing staff who dealt with his mother had been brilliant, but some other staff in the hospital did not display a lot of humanity in their dealings with patients.
Something as simple as a smile meant a lot to people who were seriously ill, he added.
Mr Kilgannon Jnr said he saw no relay of information between doctors and nurses in relation to the care being given to his mother.
He said he hoped that communication at the hospital will improve as a result of her death.