After 10 minutes on the operating table, it began to go terribly wrong
The routine operation that led to the death of Lynn Lewis is one which thousands of women throughout the UK undergo every year.
The operation to remove a fibroid from her uterus has been performed so often on patients that it is now seen as a minor procedure.
But just 10 minutes in to the surgery, which started at 9am on July 7, 2011, Mrs Lewis suffered a heavy blood loss from her uterine wall.
It began a series of events in the operating theatre which concluded with Mrs Lewis suffering a cardiac arrest.
Mrs Lewis (38) had been having problems with heavy menstrual bleeding associated with the fibroid.
Her family's private medical insurance afforded her the opportunity to have it removed at the Ulster Independent Clinic.
Surgeon, Professor Neil McClure, was an acknowledged expert in this procedure, known as a transcervical endometrial resection.
He was assisted by anesthetist Dr Damien Hughes and several theatre nurses provided by the clinic.
The mother-of-two's inquest heard that she died from a combination of haemorrhage and hyponatremia – abnormal levels of sodium in the blood which can cause the brain to swell.
Senior coroner John Leckey acknowledged in his findings that the haemorrhaging from two sites was "potentially survivable but the untreated hyponatremia was not".
The procedure to remove a benign fibroid using the 'hysterocopic' technique requires the insertion of a narrow tube with a telescope to allow the surgeon to examine inside the womb.
The Co Armagh woman's fibroid was much larger than the surgeon had expected and he needed to work fast to remove it and stem her bleeding at the same time.
Prof McClure used an irrigation fluid called glycine to give him a clear vision of where he was operating.
He opted to use a handheld tube attached to his surgical instrument to irrigate the operating site.
Prof McClure was in charge of the flow of the fluid and was informed by theatre nurses when each new bag was opened.
At one point in the operation, the fluid tube came loose, spilling onto the floor, while the surgeon had to stop to reattach it.
He was said to have been drenched with the liquid.
Critically, it was the failure to adequately assess and monitor the fluid deficit levels in Mrs Lewis's body that ultimately led to her death.
The accidental spillage further made it difficult to assess.
Although Mrs Lewis lost between one third to one half of her blood during the operation, it was the introduction of this fluid in to her body which caused a fatal swelling in her brain.
Mrs Lewis' condition deteriorated rapidly and she suffered cardiac arrest.
Despite strenuous efforts by the medical team for 90 minutes to resuscitate her, she died.
The inquest heard that all the surgical team led by Prof McClure were aware of the dangers of hyponatremia during an operation of this kind.
The risk of fluid absorption from the use of glycine is known to be greater for this procedure.
The inquest heard that normally, two bags of glycine would be used in a procedure of this kind. In Mrs Lewis' case, four were used.
Any fluid deficit left in a patient's body of between 1,000-1,200ml would gave "cause for concern". After the operation it was estimated that 10,500ml of the fluid was used and 5,700ml was collected.
The method of assessing how much fluid was introduced in to Mrs Lewis and how much was collected afterwards was found not to be standardised in Northern Ireland's hospitals.
And the results of blood tests which could have indicated potential hyponatremia were not available in time for the surgeon and the anaesthetist to analyse the results.
If they had been, the operation would likely have been abandoned.