A senior midwife has told an inquest there were "missed opportunities" to save an expectant mother who bled to death when her placenta was "ripped out" during childbirth.
Midwife supervisor Suzanne Cro said "alarm bells" should have been ringing when Claire Teague, 29, began asking for an ambulance shortly after the home delivery.
The senior health professional also told Windsor's Coroner's Court photographs of Mrs Teague's placenta indicated it was "obvious" 30% was missing, which would have shown something was badly wrong.
Mrs Teague died after she suffered a massive haemorrhage caused by the incomplete delivery of her placenta during the home birth in the early hours of August 1 2010.
At the time, the young mother was being cared for by independent midwife Rosie Kacary, who she hired when she became pregnant for the second time in 2009, after she lost one of her twins during an emergency caesarean section earlier that year.
On Wednesday, Mrs Teague's husband Simon told the hearing he watched as Ms Kacary "ripped out" his wife's placenta using "a lot of force and tugging."
Giving evidence, Ms Cro, who was drafted in to write a report for the Nursing and Midwifery Council, to see if lessons could be learned from the tragedy, told the hearing she felt Ms Kacary should have noticed the placenta was not intact.
She said: "I've looked at the photographs and it's very obvious that part of the placenta is missing.
"To me, looking at the photographs, I felt that the placenta does not look complete and would have had concerns about it."
Ms Cro also said a text message from Mrs Teague's husband Simon as he became increasingly anxious should have rung "alarm bells" with Ms Kacary.
In the message, Mr Teague reveals that his wife, who was terrified of hospitals, is asking for an ambulance.
Ms Cro said: "I would hope from that text that I would have asked for questions... it would have set off alarm bells in my mind that if she is fit and well then why does she need an ambulance.
"Especially someone like Claire who had an aversion to hospitals, I would be thinking why now does she want to go in an ambulance."
Ms Cro also said she was concerned Ms Kacary's notes of her discussions with Mrs Teague about the risks of a home birth were incomplete.
As she had previously undergone a caesarean and required a blood transfusion, the expectant mother would have been at a higher risk of complications, she said.
The inquest was told that the case was under investigation by the Nursing and Midwifery Council.
Ms Kacary was previously investigated by the regulator for another birth but was allowed to keep practising, the hearing was told.
The inquest, which is expected to finish today, continues.
Delivering a lengthy narrative verdict, Coroner Peter Bedford pointed to Ms Kacary's failure to spot the abnormal placenta, which caused Mrs Teague to haemorrhage, as a significant factor in her death.
He said: "The inspection of the placenta was conducted in poor quality and the manner of the inspection was such that she did not appreciate that approximately a third had been retained.
"I find it difficult to avoid the evidence of the experts involved who conclude that it was very obvious that there was a significant portion of the placenta missing.
"The only logical explanation I can come to is because the lighting can not have been adequate."
He also said there were "missed opportunities" to take Mrs Teague to hospital sooner, both by the failure to spot a serious tear and the failure to realise she was seriously unwell when she asked her husband to call an ambulance.
"Subsequent exchanges of texts and telephone calls between the midwife and Claire's husband gave cause to a missed opportunity to explore Claire's deteriorating condition and advise an ambulance be called and admit her to hospital," he said.
But Mr Bedford said it was not his role to lay blame on any party involved in the death.
Referring to the conflicting evidence of Mr Teague, who described watching his wife's cord being "ripped out," and Ms Kacary's testimony that she was "gentle and kind," he said he believed the truth lies "somewhere in between."
He acknowledged it had been "difficult and emotional inquest," adding: "Everyone involved has been a victim but one's heart goes predominantly to the family for obvious reasons."
He said he didn't believe Mrs Teague had been "brainwashed" into a home birth, but had undergone a traumatic birth and the loss of a child.
"I don't underestimate the impact that would have had on the young woman," he said.
"When she found herself pregnant again rather quickly I'm confident that the approach she adopted very much reflected her early experience and her wish to avoid repeating that experience."
Speaking after the inquest, Mrs Teague's father James Pragnell said he was disappointed the coroner had not gone further.
Mr Teague was not in court to hear the verdict, having found the inquest distressing.