The death of a new mum from Sydenham who suffered complications after giving birth at the PRUH was “most unusual” a coroner said.
Ms Nelson was admitted for an induced delivery at the Princess Royal University Hospital in Farnborough, where son Wesley was born on January 28 last year.
Ms Nelson's widower James Ramirez, a 37-year-old IT manager, told the court after giving birth he found Ms Nelson "delirious, spaced out and obviously tired" and pale.
Complications arose after the birth, and Ms Nelson suffered bleeding, high blood pressure and a high pulse before going into shock requiring surgery.
She had an emergency hysterectomy and had multiple cardiac arrests.
She died on February 2 after being moved to the King's College Hospital (KCH), where her family was told she needed a liver transplant.
Dr Harris said: “It is a great tragedy for a young family to lose their mother. It is most unusual to have a maternal death in a hospital of a healthy young woman.
Wesley
"The major post-partum haemorrhage protocol should have been begun and was not, as false reassurance was felt by the absence of evidence of evident active bleeding and the severity of the shock was not recognised.
"Had it begun, fluids and blood would have started earlier and consultants would have been notified earlier - but it would have made no difference to the outcome."
He said this was because Ms Nelson had "deteriorated rapidly".
The medical cause of death was repeated cardiac arrest and associated reactions to fluid resuscitation for shock before and after the emergency hysterectomy, the coroner said.
Dr Harris also said: "I think we have to accept that there are times where questions cannot be answered at an inquest. I hope this will help Mr Ramirez and his family to rebuild."
MORE TOP STORIES Mr Ramirez did not comment after the ruling, but his solicitor Caron Heyes said: “"The obstetrician had a patient who was in shock. She had protocol that said when patients go in to shock after delivery you need to instigate a major post-partum haemorrhage protocol - and she did not do that.
"She did not put up a drip. She did not make sure the fluids were being pushed in. She did not make sure her patient was reacting to resuscitation process and because of that it took much much longer for her to then get the attention she needed.
"In this case, it may be right that it could not have saved the patient but we heard that in 99.9% of cases that it would have - how awful is that mistake?"
Ms Nelson’s death triggered an internal and external investigation of the standards of maternity care at the PRUH.
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