Rebecca, 29, died on June 25, 2007 from “multi-system organ failure”, the result of a haemorrhage following an emergency C Section at Bathurst Base Hospital the day before.

“Up until then, we were filled with self doubt, like maybe we were barking up the wrong tree. But we were right, Rebecca’s death was preventable. We weren’t second guessing,” she said.

Not that the ruling has made it any easier for the family to come to terms with their loss. If anything, Missy said now it’s all over there is a feeling of “emptiness”.

“The path we have taken we had to take for the kids,” she said.

“God forbid in years to come if Grace were to think her birth caused her mother’s death.”

On the opening day of the inquest, the Greater Western Area Health Service issued an apology to the family saying they were “deeply sorry for the tragedy”. But Mrs Furner described the apology as “pathetic”.

“It wasn’t a fair dinkum apology,” she said.

It was very difficult for the family to sit through the inquest and hear that Rebecca would still be alive if things had been done better.

“Sitting through the inquest I was amazed there was nothing in place [regarding full blood counts, groups and holds and blood cross matching],” Mrs Furner said.

“I got the feeling Bathurst Hospital has implemented the changes [recommended by the coroner] but that it hasn’t happened at other hospitals across Greater Western Area Health Service.”

Mrs Furner said she feels for Jane Thompson, the anaesthetic nurse responsible for Rebecca in the recovery room, saying she should not have been put in that position.

“She shouldn’t have been the recovery nurse for an obstetric patient,” Mrs Furner said.

“There were so many missed opportunities ... they sent for 14 units of blood from Orange [under police escort] but no one had the foresight to think if they are using that much blood, why not send Novoseven [a drug with coagulation properties not available at Bathurst, but stocked at Orange Base Hospital].”