In her finding on Piyanat Siriwan's death, coroner Paresa Spanos attacked South Eastern Private Hospital and two doctors responsible for the woman, 33, after she gave birth to her first child on April 1, 2004.

After the arrival of her healthy baby girl, Nerissa, about 8am, Mrs Siriwan suffered massive blood loss. She died at Monash Medical Centre, where she had been transferred for an emergency hysterectomy.

Ms Spanos said that while the transfer between hospitals was a "study in chaos", not enough was done to save Mrs Siriwan's life as she continued to deteriorate at South Eastern Private Hospital.

"With competent medical management, including more timely and less chaotic decision-making, Mrs Siriwan had a reasonable chance of survival - in that sense I find that her death was preventable," she said.

Ms Spanos said the decision to transfer Mrs Siriwan to another hospital for an emergency hysterectomy was delayed by about 20 minutes after her obstetrician, Dr Maurice Lichter, realised the Siriwans did not have private health insurance.

He switched the transfer to Monash Medical Centre, despite Mrs Siriwan's husband Harrinat telling Dr Lichter he would pay for whatever treatment his wife needed.

The inquest heard Mrs Siriwan then went into cardiac arrest during the transfer after her anaesthetist, Dr Emlyn Williams, was not told blood had been packed into the ambulance for her.

Ms Spanos said that while she did not make adverse findings against professionals lightly, "regrettably there was compelling evidence to do so against Dr Lichter and Dr Williams for their clinical management of Mrs Siriwan."

She referred the case to the Medical Practitioners Board of Victoria to take "whatever action it deems appropriate" against the two doctors.

Mr Siriwan's lawyer, Kathryn Booth, of Maurice Blackburn, later said: "This is a case, in our opinion, of gross medical negligence and it will go down in history as one of the most serious medical mishaps in this state."

She said Mr Siriwan had issued proceedings against Dr Lichter, Dr Williams and the South Eastern Hospital for general and exemplary damages.

Dr Lichter, Dr Williams and South Eastern Private Hospital were not available to comment on the finding.