An anaesthetist attending a new mother after she underwent a Caesarean and further surgery ignored two more senior medics who told him to alter his treatment to improve her breathing before she died, a court heard.
Dr Nadeem Azeez was told to move from "bagging" Frances Cappuccini, 30, with a face mask to more invasive and intense methods as she struggled to breathe as she came round from a general anaesthetic, two other specialists who worked on her told a jury.
They gave evidence in a landmark manslaughter trial at Inner London Crown Court of South African-born consultant anaesthetist Errol Cornish, who worked on Mrs Cappuccini alongside Dr Azeez, and Maidstone and Tunbridge Wells NHS Trust, which runs Tunbridge Wells hospital where she died.
Mrs Cappuccini lost more than two litres of blood when her son Giacomo was born at the hospital in Pembury, Kent, on October 9, 2012. She was operated on but never woke up and died the same day her baby was born.
The prosecution alleges Cornish and Azeez completed failed in what it said was their "elementary task" to ensure Mrs Cappuccini safely came round from the surgery. Azeez, who, the prosecution said, was primarily responsible for the care of Mrs Cappuccini, is not on trial, having left the country.
Dr Raymond Chung, a senior consultant anaesthetist at the hospital, said he told Dr Azeez to intubate Mrs Cappuccini - passing a breathing tube directly into her windpipe - after speaking to him on the phone but found he had not done it when he arrived in the operating theatre ten minutes later at around 1.30pm.
Dr Chung, who said he was the hospital's "man in blue" on alert to deal with serious cases said Dr Azeez then seemed to fail in an attempt at intubation, forcing the senior man to take over.
He said Dr Azeez may have passed the tube into her oesophagus instead, saying: "He placed the tube into her (throat) but the oxygen measurement failed to improve. I took the decision to remove it and put it back in myself." Prosecutor John Price QC asked why it had not worked and Dr Chung said: "It may have been in the oesophagus which is the other potential route a tracheotomy tube can go down. I had already noticed that her stomach was already distended with what was probably gas."
He said that when he re-intubated Mrs Cappuccini her oxygen level improved and they used a "naso-gastric tube" to expel the air from her stomach.
The court has previously heard second-time mother Mrs Cappuccini had her son at around 8.40am but lost 2.3 litres of blood (around four pints) and was taken into theatre.
The jury has been told heard that the tube helping Mrs Cappuccini to breathe after the operation had been removed by 12.30pm but, despite apparent difficulties with her breathing after that point, there were delays in re-intubating her. She died at around 3.15pm.
A second consultant anaesthetist, Dr Garth Sommerville, told the jury on Friday he arrived to see Dr Azeez "bagging" her using a face mask and hand pump while Cornish was sitting by her side. Dr Sommerville said he spoke to them from the door and advised Azeez to instead use an laryngeal mask, a more invasive procedure which involves a device placed in the throat.
He then went to change his clothes to enter, which took two or three minutes. Mr Price asked: "What you advised was done, had it been done by the time you got back?"
Dr Sommerville said: "No."
Mr Price asked: "What was being done as far as assisting with ventilation when you first returned from changing?"
The doctor answered: "I think similar (to before). I remember just coming in and ... I took over bagging." He said that after taking over the laryngeal mask was inserted and after he shortly handed over to Dr Chung, who arrived at around the same time as him.
He left the theatre at 2.15pm. He added that his diagnosis at the time was that Mrs Cappuccini was still "partially paralysed" from general anaesthetic.
However, he said he could not remember if Cornish had still been present when he returned from changing.
Cornish, of Holmbury Park in Bromley, south-east London, has pleaded not guilty to manslaughter by gross negligence.
Maidstone and Tunbridge Wells NHS Trust, which runs Tunbridge Wells hospital, has pleaded not guilty to a charge of corporate manslaughter.
The prosecution alleges that if one or both doctors are found to be grossly negligent, causing the death of Mrs Cappuccini on October 9 2012, the trust can be said to have employed someone they knew or should have known was not suitably qualified or trained for their role. It is the first time an NHS trust has been charged with the offence since its introduction in 2008.
The trial continues.