A Dublin mum who died nine days after surgery on her varicose veins was not admitted to a private hospital because her consultant could not be contacted.
Karen McCabe (46) underwent a procedure to remove varicose veins at the Bons Secours Hospital in Dublin on August 6, 2014.
Professor Austin Leahy went on a break to his Co Kerry holiday home two days later.
On August 15, Ms McCabe died due to a blood clot in the lung, which was believed to have originated in her lower leg.
An inquest into her death heard that she presented at Beaumont Hospital on August 14 and died the following morning.
Ms McCabe - of Bewley Drive, Lucan, Co Dublin - contacted Bons Secours three days before her death complaining of pain in her knee and difficulty walking.
The inquest also heard how Dr Kingsley Opputeh wanted to admit the mum of three and carry out a scan on August 13, but only Prof Leahy could authorise Ms McCabe's admittance to the Bons Secours.
Prof Leahy had left specific instructions that he should be contacted via text message if he was needed but network coverage in the area was unreliable, the court heard. He noticed a missed call from a general Bons Secours' number and did not reply because it was not a specific number, the court heard.
Speaking following the inquest, Karen's family said "nothing can bring her back", but said they were comforted by the findings of the inquest.
Since the findings, new cover arrangements when consultants are unavailable have been put in place in the hospital.
Bons Secours Hospital manager Mike Tonery said he had personally engaged with the hospital's consultants to ensure adequate cover be organised where appropriate.
"Never again will it happen that a patient won't be able to be admitted without a consultant," he said.
Coroner Dr Brian Farrell returned a verdict of medical misadventure.