A verdict of medical misadventure has been returned at an inquest into the death of 46-year-old Karen McCabe from Lucan in Dublin.
The mother-of-three died nine days after an operation at the Bon Secours Hospital in Dublin in 2014 to remove varicose veins.
The hospital has apologised to the family.
Ms McCabe had the private operation on 6 August 2014, performed by consultant vascular surgeon Professor Austin Leahy.
The inquest has previously heard that Mrs McCabe contacted the Bon Secours on 12 August complaining of leg pain.
Prof Leahy was away on holiday at the time and received no text message about the matter.
On Wednesday 13 August, he had a missed call from the hospital but could not return it as it came from a general hospital number.
Mrs McCabe was advised to either come into the Bon Secours, go to Beaumont Hospital or see her GP but she said she was not confident of driving and did not have a lift.
She called the hospital again and after attending on 13 August was given a referral letter for Beaumont Hospital.
She attended Beaumont Hospital's emergency department on 14 August complaining of leg pain.
She died on 15 August.
Today at the Dublin City Coroner's Court, Dr Peadar Gilligan, consultant in emergency medicine at Beaumont, gave evidence of his review of the case.
He said that when Mrs McCabe attended Beaumont, she complained of severe left knee pain.
She was given painkillers and anti-inflammatory drugs and was categorised as urgent.
Her condition deteriorated and she went into cardio-respiratory arrest and was moved to intensive care.
She was given medication to stop a clot, or reduce a clot, but later died.
The inquest has heard that the Kardex chart for Mrs McCabe, which would show exactly when clot busting medication was administered, cannot be found.
A post-mortem examination report, detailed at an earlier inquest hearing, found that she died from a pulmonary embolism. She had a deep vein thrombosis and a blood clot travelled from her leg to her lung.
Mike Tonery, hospital manager, told the inquest that it had been a very rare and unusual occurrence not to have a consultant available at the time Ms McCabe re-attended on 13 August to enable her to be readmitted.
He said new systems were in place to always have consultant cover and to allow nurses to text consultants from the nurses' workstation.
