A pregnant woman who died after not accepting medical advice to attend hospital was not in a position to properly assess the risks to herself and her unborn child, a coroner has said.
Cara Officer (36) died from a rare blood disorder in June 2011.
She was 26 weeks' pregnant when she and her unborn baby Ewan died at the Ulster Hospital.
Ms Officer, from Bloomfield Road in east Belfast, was suffering from thrombotic thrombocytopenic purpura (TTP), a rare condition involving the formation of small clots (thrombi) within the circulation.
It is so rare the majority of doctors, midwives and nurses never encounter it in their careers.
An inquest, which began on January 6, had heard how Ms Officer complained of feeling unwell in the week before her death.
However, despite symptoms including pain, a drooping face and slurred speech, she did not follow advice to go to the accident and emergency department or the Ulster Hospital's obstetric unit.
The inquest was the first in Northern Ireland into the stillbirth of a baby.
Delivering his findings yesterday, Senior Coroner John Leckey said Ms Officer may have put off going to hospital because of waiting times. "I have concluded that she was not in a position to assess objectively the serious potential consequences for herself and her unborn baby of a decision not to accept the medical advice proferred," he said.
"She did not have that knowledge. Her decision-making on June 10 appears to have been coloured by her frustration at the long wait to be seen by a doctor when she attended the day obstetric unit on June 7 and by the fact that she had attended her GP that morning."
In a statement, Ms Officer's family said the hearing may provide some answers for her three-year-old daughter Eloise and partner Ryan McDougall.
"We, as Cara and Ewan's family, will never veer from our belief that Cara would never knowingly have put the life of her baby, or her own life, in danger," it read.
"We take this opportunity to remind all of those involved in the medical treatment of others that simple steps, like making a phone call or taking a blood test, could ultimately save someone's life," the statement added.
Mr Leckey was unable to say if Ms Officer or her baby would have survived irrespective of when TTP was diagnosed.
Mr Leckey said he intended to write to the Chief Medical Officer on the "difficult situation" faced by doctors where a patient chooses not to comply with advice to seek hospital intervention.
A South Eastern Health & Social Care Trust spokeswoman said: "Cara's tragic death has heightened the awareness of this rare disease which will make staff better prepared to manage a patient presenting with such an unusual condition like this in the future."
June 6 2011: Cara Officer (right) attends her ante-natal clinic. Later she calls her GP complaining of feeling ill.
June 7: Cara calls her GP.
June 10: She complains of a headache and facial pain. A friend telephones the health centre and speaks to a locum doctor, who advises calling an ambulance. Cara declines.
June 12: Cara is admitted to the Ulster Hospital, suffers a cardiac arrest and dies.