There were "serious failings" in the hospital care of a mother who suffered a massive haemorrhage and died hours after childbirth, a coroner has ruled.
Gabriela Pintilie, 36, lost six litres of blood after giving birth to her daughter via cesarean section at Basildon University Hospital last February.
Mrs Pintilie, from Grays, Essex, gave birth at 9.34pm on February 26 last year but died around seven hours later.
The Romanian-born mother bled to death over several hours after a breakdown in communication meant doctors conducting emergency surgery after the birth did not realise how much blood and blood clotting products were available.
Recording a narrative verdict, coroner Caroline Beasley-Murray told Essex Coroner's Court there was a "situation of confusion" during the "crisis events".
She said there was a "lack of leadership to deal with the situation".
She also noted the lagging of Mrs Pintilie's care in the busy maternity ward.
"There were delays in attempting the induction, there were delays in carrying out the C-section and there were delays in surgical management," she added.
Last week, the inquest heard from anaesthetist Dr Tom Hall, who broke down in court when he recounted how haematologist Asad Omran refused to issue more blood clotting products.
Dr Hall remembered describing Mrs Pintilie's blood as "looking like water".
Mrs Beasley-Murray said: "The refusal of the consultant haematologist ... was completely at odds with guidelines."
She added: "He should have been aware of the protocols for major haemorrhage."
Concluding her verdict, Mrs Beasley-Murray said:
Ionel Pintilie, Gabriela's husband, said his wife's death was "incredibly difficult to comprehend".
He said in a statement: "We trusted the doctors and nurses to keep Gabriela safe and I am so grateful for the doctors who tried to do this but others let us down us and have left me without the wife I loved since we were childhood sweethearts and our children without their devoted mother.
Stephanie Prior, partner and head of clinical negligence at Osbornes Law, who represents the family, said: "This is one of the most shocking cases of unfathomable ineptitude I have seen in my time as a solicitor.
"For the medical staff to have received the blood products Gabriela needed to save her life and then not give them to her as she bled to death in front of them is beyond comprehension."
The mid and south Sussex hospitals group offered Mrs Pintilie's family their "condolences and sincere apologies" and have commissioned an independent investigation.
Chief nurse Diane Sarkar said: "The staff involved in Mrs Pintilie's care have been deeply affected by her death and we have made changes in procedures to ensure that the same situation doesn't happen again."