Mineshaft death: What delayed Alison's Hume's rescue?
For more than six hours, Alison Hume lay injured in the darkness about 40ft down a disused mineshaft.
Up above, firefighters argued about how to save her.
The 44-year-old had fallen into the hole near her house in Galston, Ayrshire, while taking a shortcut home in July 2008.
She was found by her daughter, who raised the alarm - but when fire crews arrived they could not rescue her because of the way regulations on Safe Working at Height (SWAH) had been interpreted.
When the solicitor was eventually brought to the surface by mountain rescue experts, she suffered a fatal heart attack.
The fatal accident inquiry into her death heard that one man, Alexander Dunn, had been lowered into the mineshaft with oxygen and first aid equipment.
However, commanders ruled that the line which had taken him down could not be used to bring Mrs Hume to safety.
They insisted Strathclyde Police Mountain Rescue Team should be called, even though they did not know how long it would take them to arrive.
So, for four hours Mr Dunn was unable to do anything more than comfort her - even though, as he told the inquiry, she apparently had a swollen stomach and signs of a head injury.
The SWAH equipment used to lower him down is carried in four bags on fire appliances and is designed to prevent firefighters from falling from height, such as an unprotected ledge.
It was introduced in March 2008, four months before the tragedy. Senior officers at the scene said the regulations governing its use stipulated that it could not be used for non-fire and rescue service personnel.
A paramedic who had been called to the mine shaft was not allowed to be lowered down to help Mrs Hume.
But the man who drew up the regulations, John Bowman, said the equipment was perfectly safe to be used on a member of the public.
"It wouldn't be used for members of the fire service if it was unsafe," he said.
"It was designed to comply with working at height regulations, which it did.
"It was in use and was used to recover the member of the fire service; it was a technicality which stopped them using it for members of the public."
Mr Bowman, who has now retired, said there was no mention of health and safety in the document he had written.
A memorandum written by Strathclyde Fire and Rescue's director of operations, John Walker, four months before Mrs Hume's death had sought to clarify the situation.
The memorandum, seen by BBC Scotland, states: "This guidance does not preclude the use of SWAH equipment to secure any casualty to prevent their further injury or prevent the deterioration of the existing circumstances."
Instead of using the equipment they had, firefighters were forced to seek help from the Strathclyde Police mountain rescue team, who eventually brought Mrs Hume to the surface.
But the inquiry also heard that another team of specialists could have been contacted. The Scottish Cave Rescue Organisation (SCRO) claimed it could have been on site within 90 minutes.
Alan Jeffreys, the founder and team leader, said: "Being a civilian team we are not subject to the strict letter of the law with health and safety regulations, as indeed Strathclyde police are.
"But in a situation where there is human life involved I think some large injection of common sense is called for. I would employ the Latin expression, seize the moment and deal with the matter - and sort out the breaking of rules and regulations later."
He admitted he could not say that the SCRO could have saved Alison Hume's life, but added: "I feel we would have made a much stronger and more vigorous response to the incident."
The MSP for Kilmarnock and Irvine Valley, Willie Coffey, welcomed the publication of the sheriff's report.
He said: "We can't have a situation where officers are in fear of reprisals from their own organisation disciplinary measures for example.
"The first priority has to be to save lives and I think we lost sight of that on this occasion."