A leading surgeon and his team have been severely criticised for "personal and institutional failings" during a minor operation which ended the life of a Co Armagh woman.
A senior coroner described the level of care by the team led by Professor Neil McClure at the Ulster Independent Clinic over two years ago as "substandard".
Lynn Lewis (38) from Ahorey died from a combination of hyponatraemia and haemorrhaging after a relatively routine operation to remove a fibroid from her uterus.
This was the second inquest into the death of a young woman which the leading consultant obstetrician and gynaecologist has been criticised over.
Nurse Janine Murtagh (31) was operated on over 11 years ago by Prof McClure to establish a potential cause of infertility for her.
She died several days later from developing peritionitis from a surgical complication where her bowel was perforated and had gone unnoticed by medical staff.
Senior coroner John Leckey, who also heard Mrs Murtagh's inquest in 2004 and recommended that lessons should be learnt from her death, said yesterday that Mrs Lewis would not have died "if the appropriate measures and precautions had been taken".
His report and findings into the death on July 7, 2011, will be sent to Health Minister Edwin Poots and chief medical officer so that "lessons could be learnt".
He will also be sending his report to all medical directors of Northern Ireland hospitals to highlight the learning points of the case, particularly in relation to the monitoring of fluids introduced during the operation, which caused Mrs Lewis' fatal brain swell.
While Mr Leckey declined to make any comment on "questions of criminal or civil liability", he added: "The candid statement I received on behalf of Professor McClure, Dr Hughes and the Ulster Independent Clinic and the nursing staff speaks for itself... the failings were both personal and institutional."
After the inquest, Mrs Lewis' husband Mark spoke of the family's "bitter disappointment that Lynn was failed in so many ways".
"It is our sincere hope that the systems and individuals who contributed to Lynn's death have learned clear and powerful lessons and that they accept the responsibility they bear for their actions on that dreadful day," he said.
Stephen Murtagh, the husband of Janine Murtagh, who attended throughout Mrs Lewis' inquest, said last night: "The criticisms of the surgeon today and the surgical care are the same as they were nine years ago at Janine's inquest.
"Again, lessons should have been learnt so that no other family goes through what I did and Mrs Lewis' family. What is the coroner going to do about this?"
The inquest also heard of "significant deficiencies in team work and team dynamics when Mrs Lewis was in theatre".
Mr Leckey accepted expert medical evidence that the haemorrhage which Mrs Lewis suffered was "potentially survivable but the untreated hyponatraemia was not".
Individual failings in responsibilities were acknowledged by Prof McClure, anaesthetist Dr Damien Hughes and the Ulster Independent Clinic and nursing staff in a co-signed statement read to the inquest. All parties directly apologised to Mrs Lewis' husband Mark, her parents Jim and Marie Woods and extended family for their individual responsibilities during the operation.
Prof McClure was not present at the inquest's final day yesterday.