A coroner has criticised "repeated failures" at a high-profile abortion clinic following the death of a mother of one, hours after she had her foetus terminated.
Dr Sean Cummings said the case involving Aisha Chithira, 31, who travelled to England from Ireland to have a termination at a Marie Stopes clinic in Ealing, was "desperately sad".
West London Coroner's Court heard Ms Chithira died in January 2012 following a late-stage abortion after being discharged from the west London clinic despite vomiting and feeling dizzy, and displaying symptoms that "were not appreciated as potentially sinister".
Ms Chithira suffered a tear to her uterus during the "blind" procedure performed under anaesthetic, as a surgeon struggled to remove a 22-week-old foetus from a womb that had not fully dilated.
Afterwards she vomited and complained of feeling unwell to her husband, but was helped into a taxi to a cousin's home in Slough by staff who had told her she could not stay overnight.
Later that night the mother suffered catastrophic internal bleeding of around two litres and died.
Dr Adedayo Adedeji, who performed the procedure, and nurses Gemma Pullen and Margaret Miller were charged with manslaughter by gross negligence and a health and safety breach but the case was dropped in 2016.
Recording a narrative verdict, acting senior coroner for west London Dr Cummings said the case had been "catastrophic" for all those concerned.
After the procedure Ms Chithira had "light bleeding", complained of feeling hot, thirsty and dizzy and fell to the floor, staff at the clinic reported.
However, observations taken by a nurse showed her blood pressure and pulse were normal and doctors told the court her symptoms were "atypical" or "unlucky".
This meant her position was "difficult to diagnose and consequently the severity was missed", the coroner concluded.
He said: "Her death resulted from the manifestation of a recognised complication of the procedure resulting in sometimes subtle and atypical symptoms and signs which were not appreciated as potentially sinister at the time.
"There were repeated failures of recording of observations by different clinicians involved in her care."
Ms Chithira, who was from Malawi but settled in the Republic of Ireland, had a history of non-cancerous growths around the womb called fibroids which made the procedure more complex.
She had decided to have an abortion after miscarrying twins at 30 weeks and then having her baby girl delivered by C-section, making her worry that childbirth was too much of a risk.
She had to wait a month to obtain a visa to travel to the UK after it became clear the procedure could not take place in Ireland, and consequently due to the late stage of the pregnancy a number of clinics would not accept her.
Ms Chithira's husband Ryan said in a statement released after the verdict that his loss was "compounded by the torturous process that has seen my wife's case dragged through the courts over the past six years".
Dr Cummings identified an "element of complacency" within the west London clinic, but said he could not return a verdict of neglect as invited because he was not satisfied there had been a gross failure.
Last month Ealing Council became the first in the country to create a protest-free safe zone outside the Marie Stopes clinic after concerns for patients.
Emma Doughty, a specialist medical negligence lawyer from Slater and Gordon, which represents Ms Chithira's family, said: "It is crucial that lessons are learned to ensure a tragedy like this never happens again.
"I hope that today's verdict marks a turning point in Ms Chithira's family being able to rebuild their lives."
Richard Bentley, managing director at Marie Stopes UK, said: "We remain deeply saddened by the death of Aisha Chithira and our thoughts and sympathies are with her family.
"We have taken significant steps since 2012 to ensure that we are providing the best in abortion care and continue to do so. In particular we have effective processes in place to ensure our clients have been assessed as fit for discharge before they leave our clinics, however late in the day that may be.
"The safety and well-being of those we treat is fundamental to all that we do and we will ensure that all learnings from this case are acted upon as part of our relentless focus on delivering clinical excellence."
Dr Anthony McCarthy, from the Society for the Protection of Unborn Children (SPUC), said: "The tragic death of Aisha Chithira thanks to Marie Stopes highlights the low ethical standards of the abortion industry and their contempt not just for unborn children but for the women in crisis whom they betray.
"The coroner found of Aisha that there were 'repeated failures of recording of observations by different clinicians involved in her care', findings in line with the well over 2,600 failures found by the Care Quality Commission, alongside statements by staff to the effect that women patients were treated like cattle.
"Small wonder that Marie Stopes, which has shown little sign of reforming, wants a 'buffer zone' to stop mothers hearing about real help available to have their babies."
Some 2,634 incidents were recorded between 2015 and 2016 after CQC inspectors visited 12 Marie Stopes sites in England, SPUC said.