Northwick Park Hospital has been found guilty of neglect after a nurse died of massive blood loss following the birth of her child.
Ana Maria Denzo, 30, who was a nurse at the hospital in Watford Road, Harrow, was the tenth victim to die in three years at the maternity unit.
Staff made a catalogue of errors and missed numerous chances of saving Mrs Denzo who was given more than 40 litres of blood during a series of operations.
Hornsey Coroners Court heard Mrs Denzo's daughter, Areanne, was delivered by caesarean section but doctors were faced with torrential bleeding.
In the course of three operations her womb and a kidney were removed and Mrs Denzo lost huge amounts of blood.
Her brain was starved of oxygen and she never recovered, dying three weeks later on March 19 2005.
Giving a narrative verdict Coroner Andrew Walker told Mrs Denzo's family, who flew from the Philippines to attend the hearing: "Nothing I ever say will be enough to comfort you in this grief.
"As a result of this tragedy Mrs Denzo's daughter will never know her mother. Mrs Denzo's death was contributed to by neglect."
She was admitted to the hospital on February 23.
Dr John O'Riordan, the consultant obstetrician on duty that morning, admitted he did not examine her so that he was not aware that Mrs Denzo's baby may have been two big for a natural birth.
Midwife Florence Okpara then continued increasing the dose of a drug which contributed to the haemorrhaging and did not tell the doctor.
He said that if he had known he would have carried out a caesarean section earlier.
After seven hours of trying to induce delivery the caesarean was finally performed and baby Areanne was delivered but Mrs Denzo began bleeding severely.
Two further operations, including a hysterectomy, were carried out that evening in an effort to save her.
However, during these operations a major vein was punctured.
North West London Hospital Trust, responsible for Northwick Park, said that criticisms at the time had been dealt with. The number of consultants had more than tripled and the number of midwives increased.
After the inquest Sarah Campbell, a lawyer representing the Denzo family, said: "They have waited three long years and are satisfied to have heard all of the evidence.
"They are particularly pleased that the director for nursing was in court."
Elizabeth Robb, Director of Nursing and Midwifery of The North West London Hospitals NHS Trust, said: "I would like to reiterate our heartfelt sympathies and sincere apologies to Mr Denzo and his family for the shortcomings in the care we provided which sadly resulted in Mrs Denzo's death .
"We accept the Coroner's verdict. We appreciate how distressing this inquest and the last three years must have been for Mr Denzo and his family. We hope that the inquest has in some way provided them with a better understanding of what happened. "