Fiona Ni Chonchubhair (36), of Countess Road, Killarney, Co Kerry, who was bleeding internally, was sent from Kerry General Hospital in Tralee on a 71- mile journey to Cork Regional Hospital in an ambulance which was not equipped for blood transfusions.
When it arrived in Cork, it took another 15 to 20 minutes for the crew to locate the accident and emergency unit. What happened to her and her husband Stephen Cotter was "the stuff of nightmares and must be burnt into their memories as an example of the most disastrous incompetence", Mr Justice Sean Ryan said in High Court.
It was "scarcely credible in this day and age" that a patient suffering an internal bleed would be put into an ambulance without someone thinking of having the necessary cross-matched blood for transfusion".
What had happened involved "bad decision making, extraordinary ineptitude" and a further delay when she arrived at hospital, he said.
It was accepted by the HSE this led to "a dreadful tragedy whereby the couple's baby son Aodh died. The HSE admitted liability and apologised.
The couple, a dentist and orthodontist, had every reason to believe Ms Ni Chonchubhair was in exactly the right place, a hospital, when she experienced difficulties traced back to another operation in England, he said.
He noted Ms Ni Chonchubhair felt they were treated with some degree of indifference at Tralee.
He said he wanted to concentrate on the serious questions, that there was a transfer 71 miles to Cork when there should not have been.
When the case opened, the judge was told the HSE had carried out an internal review and made 12 recommendations to ensure it would not recur.
Ms Ni Chonchubhair, now a full-time mother of three expecting her fourth child, said she had no confidence the recommendations would be followed.
Afterwards, she said: "The reason we did this is that we don't want it to happen to any other mother going into Kerry General or any other hospital."