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The court heard that in all three cases the mothers suffered a placental abruption, a serious condition in which the placenta starts to come away from the wall of the womb.

Here, the organ is typically only examined after a poor pregnancy outcome, such as stillbirth or placental abruption, in which the placenta pulls away from the uterus wall and causes heavy bleeding.

On that occasion, the family had received good, prompt care after Phoebe had suffered a placental abruption - a serious condition in which the placenta starts to come away from the inside of the womb wall.

The coroner said that "earlier delivery would have been achieved… if the significance of the bleeding and pain had been clearly identified as an abruption."

“We know that women who receive infertility treatment have certain vascular complications, typically an increased risk of pre-eclampsia and placental abruption,” he said.