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 successfully giving birth to her daughter, Stefania, via cesarean section at Basildon University Hospital on 26 February 2019.

The Romanian-born mother from Grays, Essex, 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” and “a lack of co-ordination and team work”.

She also noted delays in 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 told the inquest: “He told me I should not be giving products because of evidence-based practice, it was the wrong thing. He started quoting research papers at me.”

Hall remembered describing Pintilie’s blood as “looking like water”.

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, Beasley-Murray said: “There were serious failings in the care Mrs Pintilie received at Basildon Hospital.

“It is not certain that with appropriate, timely treatment, Mrs Pintilie would have survived.”

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.

“The biggest tragedy is that Stefania will never know her mummy because of the failure of others.”

Stephanie Prior, partner and head of clinical negligence at Osbornes Law, who represented 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 Essex hospitals group offered 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.”