A mum died a month after the birth of her baby son after suffering a stroke triggered by an infection in her Caesarean scar.
Hayley Constable, 27, was rushed back to hospital after becoming ill and suffering severe pain a week after taking baby Alfie home from hospital.
The new mum was said to have been 'absolutely thrilled' with the arrival of Alfie in 2011, a year after enduring a miscarriage.
Her mum, Anne Constable, 52, told the inquest in to her death that she was 'so happy' and that initially, 'everything appeared fine' apart from some tiredness due to a long labour and the Caesarean section.
"There were no concerns raised at all, she spoke of the usual, breast feeding, tiredness, the normal thing a new mum would talk about," her mum, a health visitor, said.
The inquest heard that Hayley, from Ramsbottom, near Bury, had miscarried in February 2010 before finding out she was pregnant again in July 2010.
She went into labour on 25th March 2011 and was taken to Fairfield Hospital maternity unit with her partner of two years, Martin Fitzpatrick.
After labouring for two days, Alfie was delivered by C-section on March 27 because he was in distress.
Hayley and Alfie were allowed home after two days, but just five days later, Hayley texted her mum saying she had found lumps on either side of her scar.
Her mum told the hearing that Hayley had asked her to look at lump, and although she didn't 'examine' it, saw that the wound was clean and dry.
"She had mentioned this lumpiness and it was lumpy. She was reassured she had seen the midwife and it wasn't anything particularly to worry about," Mrs Constable said.
But the following day, Hayley asked her mum to visit her, and showed her the wound again, which had developed a red band of about an inch long running the length of it.
Her doctor came out and prescribed antibiotics and pain relief, but a few hours later, the pain became worse and Mrs Constable was told by the GP to call an ambulance.
Hayley was to Fairfield Hospital where her blood pressure dropped and she was unable to move.
The next day she was transferred for surgery at Manchester Northern Hospital where the infection was drained, but shortly afterwards was put on a ventilator as she struggled to breathe.
Mrs Constable told the inquest that she was informed Hayley was suffering with Acute Respiratory Distress Syndrome and might have just hours or days to live.
She was then transferred to Glenfield Hospital in Leicester, but passed away on April 22.
Recording a narrative verdict, coroner Simon Nelson said: "Hayley died due to a rare but recognised complication of necessary surgical intervention following foetal distress to her unborn child.
"No family should have to wait as long as you have had to wait for this inquest. I very much feel that it should have been concluded in a shorter time scale. I have no doubt at all that she had all the attributes you referred to.
"A very vivacious and attractive lady and I hope features of her personality continue to live on and you will see them as Alfie develops. I hope you continue to reflect on these wonderful attributes with great tenderness."
Pathologist Dr Alan Padwell said he couldn't recall a 'train of events' like Hayley's before.
"A c-section was performed because it was necessary to be performed. A recognised complication of any injury is wound infection, Acute Respiratory Distress Syndrome then developed and then a stroke," he said. "I can see how each train of event occurs but I have not seen a case like this before. It is quite rare."
The Mail reports that Hayley's devastated family said she was a 'loving and affectionate partner, daughter, sister and a friend to many' who had been 'greatly looking forward to having Alfie in her life and building a family of her own with her partner'.
"The evidence heard that certain internal guidelines were not followed and this has been a great disappointment to the family who feel this would have made a difference," they said.