A coroner has returned a verdict of medical misadventure in the case of a woman who died during surgery for an ectopic pregnancy.
Malak Thawley, 35, of Brusna Cottages, Blackrock, Co Dublin died on 8 May 2016 at the National Maternity Hospital in Dublin.
In a statement read out by his solicitor after the inquest, her husband Alan Thawley said he has not lived a "single minute of his life" since her death.
"I just wish I could return to my old life. The one where the love of my life was still alive and we were expecting our first child. My life after my wife's death has been a never-ending nightmare," he said.
"The morning of my wife's death I was quite honestly in the happiest mood I had ever been in my life. My best friend, soul-mate and love of my life was pregnant with our first child ... It is utterly devastating how much a single event can destroy a person," Mr Thawley said.
The final day of evidence at the inquest at Dublin Coroner's Court heard that the second year registrar conducting the surgery called for a senior consultant at 4.51pm after unexpected bleeding into the abdominal cavity was discovered.
However, the source of bleeding was not identified until 5.44pm, following the arrival of Vascular Consultant Mary Barry from St Vincent's Hospital.
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Ms Barry said she received a call at 5.18pm informing her that a vascular surgeon was required urgently at the NMH because "a patient was bleeding to death on the operating table".
She arrived at 5.35pm.
"The patient was completely collapsed, with no cardiac output and no pulse," Dr Barry said.
Her first aim was to reinstate circulation and she commenced internal cardiac massage.
"At that point addressing the vascular injury was secondary," Ms Barry said.
At 5.44pm she identified the source of the bleeding and repaired the tear to the aorta with stitches.
Consultant Obstetrician and Gynaecologist at the NMH, Dr Declan Keane, arrived at the hospital at 5.03pm.
"The moment I saw the fallopian tube was intact (not ruptured as suspected), I called the vascular team at St Vincent's," he said.
Asked why he did not immediately put the vascular team on alert, due to the known risk of vascular injury, Dr Keane said he accepted he could have.
"But in 28 years I have not encountered that before," he said.
Asked if the surgical instrument known as a trocar had gone too far in its initial insertion by the registrar, Dr Keane replied, "I think that is the likely cause. "
Asked if the use of an 'un-bladed trocar' was a safer option, Dr Keane replied that there is a move towards a "more direct entry, for safety purposes."
"We are probably going to see more senior personnel coming in to carry out laparoscopies," Dr Keane said.
He told the court that the risk of aortic injury is one in 1,000 cases and he had never seen such an eventuality before.
A document aimed at promoting safety in relation to this kind of keyhole surgery is being drawn up, Dr Keane said.
The inquest heard that Mrs Thawley's pre-operation blood sample was taken and stored in the fridge at 3pm.
Medical scientist Ian McCarthy said the hospital operated an on-call weekend service whereby blood samples were not processed if blood products were not required. This has since changed.
It took 45 minutes to identify Ms Thawley's blood group following a request from the operating theatre at 4.56pm.
There were 11 units of O negative blood (which can be used with any blood type) available in the hospital; four in the operating theatre and seven in the lab, the court heard.
From 5.42pm until 6.20pm there was no blood available in the lab, the court heard.
"There were times we had no blood products in the lab, I don't know if they ran out in theatre," Mr McCarthy said.
Staff continued emergency efforts to save her life, but Ms Thawley was pronounced dead at 7.57pm.
The cause of death was a tear in the abdominal aorta during the course of surgery for an ectopic pregnancy.
NMH chairman Nicholas Kearns said a "robust internal review" had begun the day after Mrs Thawley's death.
"We know that nothing can bring Malak back. However we are determined to continue to implement all that we have learned from this investigation in our clinical practice," he said.
He said the hospital apologised unreservedly for the shortcomings in Mrs Thawley's care.