The death of a young mother just hours after she gave birth to her second son was a result of "failures, inadequate diagnosis and treatment" at the hospital caring for her, a coroner has said.
Frances Cappuccini, 30, died at Tunbridge Wells Hospital in Pembury, Kent, shortly after giving birth to her son, Giacomo, by Caesearean section.
The school teacher suffered heavy bleeding and was anaesthetised, but went into cardiac arrest and died at 4.20pm on October 9 2012.
The inquest at Gravesend Old Town Hall in Kent heard that Mrs Cappuccini lost more than two litres (around four pints) of blood after the C-section.
She was subsequently operated on for a postpartum haemorrhage but never woke up from the anaesthetic.
The inquest criticised the care given to her, including a piece of placenta that was left in her womb.
Senior Coroner Roger Hatch said the Caesarean section was not carried out with enough care and that checks should have been made to ensure nothing was missed.
He added: "The result of this failure led directly to the subsequent series of events which tragically led to the death of Frances."