The mother of a young woman who died following what was described as a "series of egregious errors" in her care at the Regional Hospital Mullingar in 2021 described her as "full of fun and a bit mischievous".
Alison Sainsbury said her 25-year-old daughter Bryonny achieved a remarkable amount during her life, and people still come up to her and her husband to tell them how they met Bryonny and that they would never forget her.
Bryonny Sainsbury, from Briskil, Newtownforbes, died after being crushed by a horse while assisting with a veterinary procedure at a riding stable in Co Longford on 26 August 2021.
Her mother said the inquest and court case into Bryonny's case have answered some, but not all, of the family's questions.
"We've got an apology, but that's over four years. We had a letter on 13 October 2021 - just over a month after Briony died - from Mullingar hospital, saying that they were putting a review team together," she said.
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"So they knew that they'd done wrong, yet they still put a family through more trauma when you're trying to grieve your only daughter."
Speaking to RTÉ's Today with David McCullagh, Ms Sainsbury described how her daughter was injured during an incident treating a horse in Longford on 26 August 2021.
She said Bryonny was brought to hospital, but she and her husband Chris were unable to attend due to Covid-19 restrictions at the time.
They waited in the carpark until Chris managed to persuade them to allow his wife to go in to see their daughter.
She said she found out at that point that Bryonny had had a CT scan but was not put onto a ward until later.
Her daughter had "a little bit of conversation" but "wasn't making any sense", she said.
"She was in and out hallucinating. She wasn't good ... I said to her dad, she's not good, she's worse, if anything," Ms Sainsbury said.
"Now we could see that it wasn't being taken seriously, as far as we could see."
When asked why her daughter had not been transferred to Beaumont Hospital in Dublin, she said they were told she "wasn't bad enough".
"We found out in the inquest that the consultant that Bryonny went in with on Thursday 26, on 27 they were given a care plan for Bryonny," she said.
"Blood should be done regularly, neuro checks ... any any deterioration, it should have been forwarded on to Beaumont - anything at all.
"The vomiting, the headaches, everything, disorientation, nothing was forwarded on to Beaumont at all. So as far as Beaumont were concerned, Bryonny was okay."
Ms Sainsbury said the family received a "frantic" phone call at 7 o'clock on Sunday morning asking them to come to the hospital.
Bryonny was then transferred to Beaumont and Ms Sainsbury said she and her husband were told not to follow the ambulance to Beaumont because it would be going on all blues.
Despite this, it was an hour and a half before the ambulance arrived, she added.
"We got there an hour and a half before that ambulance arrived. I know they've got to put a patient into the ambulance, and it takes time, but we went and then got a coffee," she said.
"We walked back to the car, and then we went up."
Ms Sainsbury said a consultant at Beaumont Hospital told her that her daughter had had a CT scan and was brain dead.
She said this was despite the fact that none of her injuries were initially life threatening, adding that she believes Bryonny would not have even needed an operation if she had been treated properly.
"It was total lack of care and medication," she said.
Ms Sainsbury said her daughter always wanted to help people and two of her kidneys were donated to give others a new lease of life.
She said she hopes the HSE follows through on its promises for change.
'How do we know that this is not going to happen again?'
The family's solicitor, Karen Clabby, said the Sainsburys agreed in 2021 to participate in a review process into Bryonny's death because they wanted answers, and to ensure that if systems failures occurred, it never happened again.
"It was actually July 2024 before the hospital Review Group published their report, and in that report, they found ten faults and made 15 recommendations arising from this tragic loss of Bryonny Sainsbury," she said.
"This is how the family wants Bryonny's memory to continue, because they feel that the system has failed their daughter."
Speaking on the same programme, Ms Clabby said that while the HSE had committed to making changes, the family wants to know how they will be implemented.
"How do we know that this is not going to happen again? Because we've heard it from Mullingar to Limerick to Sligo," she said.
"It's a country wide issue, and the regional health care system needs to be examined, and I feel that this has to come from the top down."
Ms Clabby said the various processes the family has gone through have only added to their distress and anguish.
If the HSE sticks to its firm commitments, that will be Bryonny Sainsbury's legacy, she added.
