Systems are being changed and midwives given specialist training after a women died in childbirth at University Hospital of Wales.
Ifrah Hureh, 38, originally from Somalia, died of an intracranial haemorrhage after being given Syntometrine to stimulate the womb and help deliver the placenta.
An inquest heard that high blood pressure, and the fact that her pregnancy had been deemed high risk because of nine previous births, meant she should not have received the drug.
Says Sue Gregory, nurse director of Cardiff and Vale trust: “We have carried out an internal investigation to establish more about the circumstances.
“This investigation uncovered deficiencies in the care we provided to Mrs Hureh and helped us identify changes to our systems and practices to reduce the risk of such a sad event happening again.
“We now also ensure our midwives undertake specialist training to help identify and treat critically ill women.
“We would like to reassure Mr Yassin and the public that we have learned from this incident, and improvements have been made in the women’s unit as a result.”