After 14 years without answers, the family of cancer patient Joyce Spratt have been told lessons learned from her death have saved lives.
The mother-of-three, from Crossgar, was 53 when she passed away on March 22, 2002, in Belfast City Hospital.
She died from an extremely rare condition, typhlitis, a side-effect of her chemotherapy treatment.
A 2005 inquest into her death was quashed after an official complaint from her husband of 32 years, Robert 'Bobby' Spratt.
In the week of her death, there were delays admitting Mrs Spratt to hospital. She had also signed up for an experimental clinical drug trial. Mr Spratt has long believed these factors contributed to his wife's death.
The family's legal team also questioned why a crucial report on Mrs Spratt's death, compiled in 2008, was only delivered to the court for the first time by 10am on Wednesday morning.
Yesterday, the coroner, Joe McCrisken, presented his findings after a two-day inquest.
He said the typhlitis, which led to a fatal infection of the bowel, was caused by her chemotherapy and there was no link between her death and the drug trial.
Addressing the family, Mr McCrisken added: "The clinical trial she gracefully and bravely took part in was a success. As a result, the lives of many women have been saved or extended, and their families have benefited as a result."
Delays in Mrs Spratt's hospital admission were also examined.
An appointment at the City Hospital's cancer unit on March 19, 2002, was considered a crucial point in the case. Dr Paula Scullin, a registrar oncologist, decided at the time that Mrs Spratt was not unwell enough to be admitted to hospital.
"It's fair to say most of the family criticism and concern relates to the examination by Dr Scullin," said Mr McCrisken.
A high temperature from Mrs Spratt on that day could have been a sign of infection, but Dr Scullin did not record the temperature in her notes. The family said this could have been a vital slip-up.
However, Mr McCrisken ruled: "I find as a fact that Mrs Spratt did not have a high temperature. Although Dr Scullin did not record the temperature in the notes - which she accepts as a failing on her behalf - I accept this was because the temperature taken was normal."
He added: "That Mrs Spratt was suffering from a life-threatening condition as a result of her chemotherapy was tragically coincidental."
On March 20, Mrs Spratt called a hospital emergency line at 8.16pm. She did not receive antibiotic treatment in the City Hospital for another three hours. After considering two official reports, Mr McCrisken said if she had been admitted after 8.30pm, there would have been "a slightly better chance of recovery from typhlitis", which he estimated to be below 20%.
He added that even if her treatment had started on March 19, her typhlitis and ovarian cancer would still have made survival chances as low as 6 to 10%.
Mr McCrisken said there had been a "considerable amount of learning" by the Belfast Trust from Mrs Spratt's death from typhlitis. "Frankly, no one had heard of it, not just in Northern Ireland but in the UK before 2002," he added.
"On reflection, I think Mrs Spratt's family can be satisfied that lessons have been learnt, and as a result of various inquiries lives will be saved in the future and have already been saved."
Speaking afterwards, Mr Spratt said: "She was a wonderful woman, always wanting to help." The family solicitor added: "The family are very proud of Joyce. She was very courageous."
He said that the family appreciated the Belfast Health Trust had acknowledged and apologised for their mistakes, which put them "at a certain amount of ease."
He continued: "It's unfortunate it took 14 years for the evidence to be presented.
"We were presented yesterday morning with vital evidence (a 30-page report from oncologist Professor Christopher Pool) that was available many years ago.
"We are satisfied that the Trust has taken on board the learning from this case."