Objective: We sought to examine how an eyewitness partner describes the clinical and institutional conditions surrounding a Black maternal death following childbirth, and how these accounts, when triangulated with regulatory findings, can inform public health approaches to preventing maternal morbidity and mortality among Black women.Methods: We conducted an in-depth qualitative case analysis using a transcribed eyewitness interview with the decedent’s partner, who was present from hospital arrival through acute deterioration, cardiopulmonary arrest, and attempted resuscitation. The eyewitness narrative documented barriers to access, stigmatizing intake processes, symptom escalation, and emergency response failures. These data were triangulated with a Centers for Medicare and Medicaid Services (CMS) hospital survey identifying systemic deficiencies in emergency preparedness and venous thromboembolism (VTE) risk assessment and prophylaxis within labor and delivery, including an Immediate Jeopardy determination. Data were analyzed using thematic informed by public health and patient safety frameworks.Results: Four themes characterized the eyewitness account: (1) barriers to safe and respectful entry into care; (a (2) stigmatizing assessment and erosion of trust during admission; (3) dismissal and normalization of acute maternal deterioration prior to collapse, (4) failure-to-rescue during maternal arrest, including delayed emergency response, nonfunctional equipment, and the partner initiating cardiopulmonary resuscitation. These themes aligned with the CMS-documented institutional failures related to emergency readiness and VTE prevention.Conclusions: Eyewitness testimony reveals preventable pathways to Black maternal death that are often obscured in clinical documentation alone. Incorporating partner and family eyewitness accounts into maternal mortality surveillance may strengthen public health efforts to identify institutional failures, improve emergency preparedness, and advance equity in maternal outcomes.Précis: Eyewitness accounts of maternal death illuminate institutional failures in access, escalation, and emergency response that contribute to preventable Black maternal mortality.