A hospital was accused today of neglect in the death of a nurse who died after a Caesarean.
First-time mother Ana Maria Denzo, 30, bled to death after the February 2005 operation at her own hospital, the Northwick Park in north west London.
North London coroner Andrew Walker recorded that Mrs Denzo's death was "contributed by neglect" and there had been "ongoing failures" in her care.
Mrs Denzo, of Ealing, west London, was the 10th death at the maternity unit in three years, sparking an investigation by the Healthcare Commission.
She was admitted just after midnight on 23 February 2005.
In a slow labour she was given the drug oxytocin, which stimulates contractions, but no progress was made, north London's Hornsey Coroner's Court was told.
The coroner ruled: "Mrs Denzo's death was contributed to by neglect as the delivery of her baby would have taken place when the use of oxytocin had produced hyper contraction of the uterus without any progression of her labour."
The baby, a healthy girl called Areanne, was delivered at 4.05pm.
Petite Mrs Denzo was expecting a large 8.4lb baby, a potential delivery issue, the court heard.
After the birth, Mrs Denzo suffered a haemorrhage.
She was later brought back into surgery and had a hysterectomy when she suffered a tear to a vein. It is unclear how this happened, the court heard.
Overnight Mrs Denzo suffered a catastrophic loss of up to 10 litres of blood. She was brought back into surgery the next morning.
The coroner ruled: "From 10.30 in the evening there were ongoing failures in the care of Mrs Denzo which represented a lost opportunity to treat the haemorrhage from the injured vessel."
She was transferred to St Mary's Hospital in Paddington, central London, but died on 19 March 2005.
Her family, including husband Arnulfo Denzo and her parents, who had travelled from their home in the Philippines, held back tears as the coroner delivered his narrative verdict.
The coroner said: "Nothing I will be able to say will be enough to comfort them. As a consequence of this, Mrs Denzo's daughter will never know her mother."
The family left court without comment.
After the hearing Elizabeth Robb, director of nursing and midwifery at the North West London Hospitals NHS Trust, said: "We accept the coroners' verdict.
"We appreciate how distressing this inquest and the last three years must have been for Mr Denzo and his family.
"We hope that the inquest has in some way provided them with a better understanding of what happened."
She said that the Trust restated its "heartfelt sympathy and sincere apology to Mr Denzo and his family for the shortcomings in the care we provided which sadly resulted in Mrs Denzo's death."
The Trust is determined that "lessons are learned" from the tragedy, Ms Robb said.
In light of Mrs Denzo's death it has developed a new policy on the management of major obstetric haemorrhages and the use of certain drugs.
Ms Robb also said they continually "closely monitor" its maternity services.
Increases to staffing levels on the labour ward have been made.
There has also been a £19m refurbishment and a "complete review" of clinical guidelines, she said.