Jessica Palmer suffered septic shock

Jessica Palmer died from an infection after giving birth in June last year.

Elizabeth Pygott recorded a verdict of natural causes after a two-day hearing in which a midwife admitted making a mistake in not raising the alarm.

Ms Pygott said: "Had Mrs Palmer been readmitted (to hospital), it is likely that death would not have occurred."

Mrs Palmer, 34, was discharged from Kingston Hospital in south-west London after giving birth despite an abnormal temperature.

Many lives have been shattered by a tragedy that I believe could and should have been avoided Ben Palmer

West London Coroner's Court heard that Mrs Palmer spent four days at home in increasing pain.

Despite raising concerns with medical staff it was not until she saw her doctor face-to-face that she was rushed to hospital suffering septic shock - she died from a cardiac arrest.

In summing up, deputy coroner Ms Pygott cast doubt on the honesty of one doctor's evidence and highlighted the midwife's mistake but did not formally identify neglect as the cause.

'Joy and expectation'

She told the court that despite the failure of midwife Karen O'Connor to read the warning signs - a fever and a hot red patch on Mrs Palmer's skin - and tell a GP, she accepted that there had been a "full examination".

Speaking after the hearing Mrs Palmer's husband Ben said he was astounded and surprised by the ruling.

"My wife lost her life... at a time that should have been filled with joy and expectation.

"Many lives have been shattered by a tragedy that I believe could and should have been avoided."