Premalatha Jeevagan, 27, was expecting her first baby. She had experienced a normal pregnancy when she turned up at Northwick Park Hospital, four days after her due date. Eight days later, after a caesarean section, she died. Doctors failed to notice that her womb was filled with three litres of blood - 60% of her body's quota. Staff only discovered the bleeding after she had a heart attack.

Today's report details a catalogue of errors and reveals that Mrs Jeevagan was seen just once in seven days by her consultant obstetrician and her induction was stopped and re-started four times in five days.

It notes that: the locum obstetric registrar attending her after the birth was "out of her depth" for failing to notice her rapid heart beat and not checking for internal bleeding; it was "inexcusable" that the locum only came to the hospital after being called three times; and there was "seriously inadequate" postnatal care from the midwives.

Yesterday, her husband, Selvaratnam, 35, said: "She was the eighth woman at the hospital to die so why did this happen? They could have prevented it. They should get rid of most of the management." Mr Jeevagan, a service engineer from Greenford, said that he had repeatedly questioned why his wife had to wait for seven days before her caesarean "but you can only ask; you can't force them", he said.

"They made mistakes from day one: they took blood samples but didn't get results for two or three days; they gave her a blood transfusion and were supposed to give three units but only gave two; and when they took a blood sample on the night she died, it wasn't sent to the lab but remained sitting on a table.

"After the caesarean, she was brought back to the ward and my sister-in-law, who's an obstetrician, noticed her blood pressure going down and alerted staff. But the midwife just checked her fluid. [Later], her hand was shaking and my sister-in-law said it was the loss of blood from her brain ... I walked out. I couldn't stand the situation. I was in the hallway outside the ward when she died."

He is now preparing to look after their two-year-old daughter, Latchikah, who has been living in Canada with her maternal grandmother. "You can't forget what happened," he added. "I have to live with this all my life."