When the ambulance, sent from Kerry General Hospital in Tralee on a 71-mile trip to Cork Regional Hospital, arrived with Ms Ni Chonchubhair (36), who was nearly 32 weeks pregnant and bleeding internally, it took another 15 to 20 minutes for the crew to locate the accident and emergency unit, the court heard.
Ms Ni Chonchubhair, of Countess Road, Killarney, Co Kerry, was operated on and received six units of blood to replace what she had lost, but it was too late for the baby who was delivered stillborn by emergency Caesarean section on May 16, 2009.
Yesterday, on the opening day of Ms Ni Chonchubhair's action against the HSE over negligence and breach of duty, counsel for the HSE Emily Egan offered her client's apologies for what had happened to her and her husband Stephen Cotter.
Liability was admitted and the case is before Mr Justice Sean Ryan for assessment of damages.
The court heard the HSE had carried out an internal review of what happened to Ms Ni Chonchubhair and made 12 recommendations to ensure it would not recur. However, she told the court she lacked any confidence that the recommendations would be followed.
In her action, Ms Ni Chonchubhair, who gave up her job as a dentist and is now a full-time mother of three with another child on the way, is claiming damages for severe personal injury and shock.
She claims she continues to experience flashbacks of the trauma and has intermittent outbursts of anger, emotional detachment, broken sleep, poor concentration and loss of interest. She experiences anger towards the hospital and feelings that what had happened should never have happened, her counsel Eugene Gleeson told the court.
Had she received a transfusion en route, she would have suffered a less severe level of hypovolemic shock which resulted in the baby not getting enough oxygen, he said.
It was their case that there was a "tragedy of errors" which began with the decision to transfer a critically ill woman to another hospital in an ambulance which did not have cross-matched blood on board, compounded by a 20-minute delay in finding accident and emergency, counsel said.
Ms Ni Chonchhubhair told the court that she became so anxious to avoid a repetition of what happened that in her two last pregnancies, for the last three months of each, she rented a house in Cork to make sure she would be near Cork Regional and not Kerry General.
Her husband Stephen, an orthodontist, told Mr Justice Ryan that as health professionals, their confidence in general had been "shattered".
It was left to him to break the news of Aodh's death to his wife. He said he brought the baby in and asked Fiona what she wanted to call him. "There was a couple of names and she said Aodh," he said. But, he said, his wife "was a shell, she was white and spaced out and when she saw Aodh, she could not understand it, it was disbelief that he was taken away".
Fiona had been a happy-go-lucky person but gave up socialising and did not like to go out, particularly around Tralee where she felt she might meet doctors and midwives, he said.
The hearing continues.