The jury in the case returned a verdict of medical misadventure in the case, deciding that Olive McGuire died as a result of acute fecal peritonitis, where her abdomen became fatally infected, along with damage to her a cerebral artery and a perforated bowel with severe internal adhesion.
They had earlier heard from the Chief State Pathologist, who said that a punctured artery that allegedly went “unrecognised" by a doctor during a medical procedure was "likely" to have formed a blood clot which resulted in a stroke - causing the brain injury - and contributed to the death of the mother of two in 2009.
The 32-year-old was readmitted to St Luke's Hospital in Kilkenny with abdominal pain, vomiting and constipation on Saturday 13th June 2009, having been discharged the day prior as her condition was deemed satisfactory by medical professionals.
During the second admission, Ms McGuire, who was from Ballickmoyler, Co Carlow, was placed into intensive care on a ventilator having suffered a blood clot and stroke, later dying on 24th June 2009, 11 days after she was admitted.
Following her death, discussions took place between her consultants as to the cause of her death and a second post-mortem was arranged in advance of Ms McGuire's burial.
This was blasted by the family's barrister, Raymond Bradley SC, who said there was "not a screed of paper" to be found in connection with those talks.
He pointed to how the pathologist who carried out the post-mortems had himself noted there was "scant detail" provided to him on Ms McGuire ahead of him carrying out his examination.
Mr Bradley alleged this meant a “fundamentally flawed and inaccurate” post-mortem that was “compromised before it ever got started".
It resulted, he said, in the family's "grief being disrupted, with the retrieval of Ms McGuire's body from her wake overnight, and "the body of a wife, a mother, traversing the countryside" for the second post-mortem a the hospital, before being returned hours later "in time for the funeral".
"That's a consequence of the lack of detail being provided," he said, "and that's wrong for the children, that's wrong for Olive McGuire, that's wrong for her husband."
He added: "I never want to see a post-mortem report referencing 'scant detail'[again]."
The jury heard of delays in getting a brain scan for Ms McGuire, with retired consultant general George Nessim recalling "shouting on the phone" so he could get her admitted into University Hospital Waterford after the machine in St Luke's broke down.
On this, the jury called for a "second CT scanner to be acquired as a matter of urgency" for St Luke's.
Among their recommendations, they said future intravenous insertions should be guided by use of ultrasound equipment, on which the coroner said "a certain degree of comfort" was given by the hospital's Clinical Director Gary Courtney, who said that method is now used in St Luke's.
The jury also said all hospitals should incorporate a recording system to ensure that all notes are legible, complete and consistent.
During cross-examination, Chief State Patholigist Linda Mulligan said she was "surprised" the punctured artery was still not noted during the second examination of the late woman's body.
She said that on the "balance of probability" it was likely that the punctured artery had led to Ms McGuire developing a clot which caused a stroke.
She added that the bowel perforation as suffered by Ms McGuirecan becomes terminal in a matter of hours or days, and that it is a "surgical emergency" as the "leakage of bowel contents has a very high mortality rate".
Ms Mulligan said that as the patient had entered a “deep coma”, she was also unable to speak about any pain experienced from the perforated bowel, which the court heard went undiagnosed until the post-mortem.
Coroner Tim Kiely said evidence from earlier in the inquest from a radiologist put it that the clot could occur from the damaged right carotid artery in her neck, with the timeline for this to take place "about 24-72 hrs" after the puncture, "which would bring us back to the 17th" - when the artery was punctured.
Prof Mulligan said on the "balance of probability then yes it is likely that it occurred" from the puncture.
The inquest heard that the locum consultant anesthetist who allegedly punctured the artery, Dr Norbert Lederer, was no longer within the jurisdiction and was not available to give evidence.
His deposition statement, which was read into the court record by the coroner, included him saying he "inadvertently punctured" the right carotid artery in Ms McGuire's neck during a "difficult placement" of a catheter tube.