A British coroner ruled recently that a nurse's death from massive bleeding after she gave birth by caesarean in her own hospital resulted from neglect and failings in the maternity unit.
Last month, the coroner recorded that the woman's death three years ago was "contributed by neglect" and there had been "ongoing failures" in her maternity care at Northwick Park Hospital in London.
Her death was the tenth at the hospital's maternity unit in three years, and has led to an investigation by the NHS watchdog, the Healthcare Commission.
After giving birth the mother was brought back into surgery for a hysterectomy when she suffered a torn vein. It was unclear how this happened, the court heard. Overnight, she suffered catastrophic blood loss.
The coroner said in his verdict: "From 10.30 in the evening there were ongoing failures in (her) care which represented a lost opportunity to treat the haemorrhage from the injured vessel."
After the hearing, Elizabeth Robb, the director of nursing and midwifery at the North West London Hospitals NHS Trust, said: "We accept the coroner's verdict.
"We appreciate how distressing this inquest and the last three years must have been for the family. We hope that the inquest has in some way provided them with a better understanding of what happened."
The trust was determined that "lessons are learned", Robb said.
The maternity unit was put under close NHS supervision in 2005 after it was disclosed that the death rate for new mothers at the hospital was far higher than the national average. Ten women died there between April 2002 and April 2005.
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