A young mother who developed complications during a home birth died after a midwife lacked the confidence to inject her with fluids, an inquest was told.

There was also a delay in giving Joanne Whale treatment that could have saved her life in hospital after another midwife failed to pass on information to the doctors there.

Dr Peter Dean, the Greater Suffolk Coroner, said that lessons must be learnt from her death and that women should be made more aware of the dangers of home births. He also demanded better communication between midwives and doctors.

Miss Whale, 23, gave birth to a healthy boy at home in Ipswich last September. But she died hours later after a severe haemorrhage.

When Ms Whale began to lose blood she needed an injection of fluids. Julie Bates, a midwife, said that she had been trained in the process but had never had to use it. “I’ve got the theoretical knowledge but not the practical knowledge,” she said. “I felt uncomfortable having to do that in this situation.” She added: “Knowing the ambulance was only a few minutes away I thought it was better to leave it for the proper paramedics.”

The inquest was also told that Miss Whale’s arrival at hospital had been delayed because the paramedics had found it difficult to remove her from an upstairs bedroom. Martin Hambling, who was in the first of two ambulances to arrive after a 999 call, said: “Extraction was extremely difficult because of the layout of the house. We had to negotiate several sharp turns.”

Miss Whale was taken to Ipswich Hospital but doctors were not told the exact nature of her condition, which led to a delay in getting her to the operating theatre. Sarah Hall, another midwife, admitted that she did not pass on information that Miss Whale had suffered an inverted uterus during labour.

Marlar Raja, a specialist registrar in gynaecology at the hospital, said that the patient would have been taken straight to the theatre if she had been made aware.

Balroop Johal, a consultant gynaecologist, said: “The staff were expecting a retained placenta. If they had been told that it was a complete inversion of the uterus she would almost certainly have gone straight to theatre and I would have been ready for her.”

Dr John Chapman, who carried out the postmortem examination, said that Miss Whale died as a result of the inverted uterus causing a uterine haemorrhage. Her body was in so much shock that her blood failed to clot, adding to extensive bleeding.

Dr Dean recorded a narrative verdict of death from complications after an obstetric home delivery. He said he was surprised that midwives would not be confident in injecting life-saving fluids. “It does worry me a lot that mothers are giving birth in the community and the first line of call is the midwife, who might not be able to get fluid into her in those crucial early moments. That needs to be addressed.

“We can’t be certain that, had these things been done, she would have survived. All we can say is the chances of survival would have been greater.”

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