Malak's death must not be in vain - there are lessons to learn
It was a simple operation for an ectopic pregnancy that went horribly wrong - costing a young woman her life and leaving her husband Alan crushed with grief.
The final hours of the life of Malak Thawley (34), who suffered a fatal haemorrhage after a major blood vessel was accidentally pierced during keyhole surgery in the National Maternity Hospital in Holles Street, emerged in the coroner's court this week.
The operating surgeon was an experienced second-year specialist registrar trained in independent keyhole surgery.
An injury to a blood vessel during this kind of surgery is rare. When the unexpected blood from the patient was initially seen there was confusion over whether it was due to a ruptured ectopic pregnancy or a tear.
The abdomen should have been opened immediately to stop the bleeding, coupled with blood transfusion. But this did not start until 15 minutes after the initial alarm.
Ms Thawley lost most blood in the first seven minutes. There are major lessons to be learned for all hospitals from the tragedy.
Not least of these is the need to reduce risk to patients having emergency surgery on Sundays.
Hospitals function with reduced staff at weekends.
Senior doctors are on call and may be in the hospital doing ward rounds over a weekend - but for the most part they can be at home while alert to any emergency call.
Three senior doctors called to the theatre after Ms Thawley responded promptly and drove to the hospital without delay.
However, an internal report commissioned by the maternity hospital has recommended consideration be given to having a senior obstetrician and anaesthetist on site at all times.
Questioned at the inquest, obstetrician Dr Declan Keane estimated an extra eight to 12 consultants would be needed for 24-hour cover.
A new national maternity hospital is to be built on the campus of St Vincent's Hospital.
This is still some years away, but while the practical effect will be more access to a range of consultants, weekend cover is still expected to be an issue.
The way the hospital's blood service is managed was also raised at the inquest.
Ms Thawley gave a blood sample before the surgery but the practice was not to test for the blood group if it was taken on a Sunday until Monday.
It meant her blood group was not known when she started to haemorrhage although she received emergency supplies.
That practice has now changed and all blood samples are tested even on Sunday, the inquest was told.
The internal hospital report recommends the hospital install a "red phone" in theatre for use in emergencies to contact the laboratory where blood supplies are stored.
The hospital is also revising the kind of surgical instruments it uses in keyhole surgery for ectopic pregnancy.
There was a choice on the day of a bladed or non-bladed instrument. It was the bladed version which cut the blood vessel. Guidelines are expected to recommend the unbladed instrument be used in the future.
A senior consultant is also to carry out this surgery from now on.
Vascular clamps had to be ferried to Holles Street from St Vincent's Hospital and the report has called for these to be available in-house.
There also needs to be a tray of instruments to allow for the quick opening of the abdomen at the ready in the theatre.
Alan Thawley has said that if the enormous loss of his wife is to have even some meaning, more patients can not be put at risk.
He wishes every day that he could return to his old life.
"There is no way to ease the suffering or alleviate the pain," he said.
"My mind is entirely focused on that day."