Medics treating young mum who died after suffering severe blood loss during botched C-section DIDN’T KNOW which doctor was in charge

MEDICS treating a mum-of-two who died after an emergency C-section did not know who was in charge during the surgery, an inquest heard.

Frances Cappuccini, 30, suffered a heart attack and died eight hours after the birth of her second son, Giacomo.

The primary school teacher lost four pints of blood during the birth at Tunbridge Wells Hospital, Kent, in October 2012.

An inquest into the death today heard there was confusion around the system of appointing an on-duty consultant.

Previous reports found Mrs Cappuccini had acid in her blood due to a lack of oxygen, allegedly because of failures from the anesthetists.

Two consultants, Dr Errol Cornish and Dr Nadeem Azeez, along with Maidstone and Tunbridge Wells NHS Trust, were charged with gross negligence manslaughter.

The trust made legal history by becoming the first NHS Trust to face corporate manslaughter charges for allegedly failing to check the doctors were properly qualified.

But the allegations were dismissed by a judge at the Inner London Crown Court in February last year.

An inquest into the death today at Gravesend Old Town Hall heard Dr Azeez failed to make sure Frances’s airway was clear following surgery to treat the severe haemorrhage.

At an earlier inquest hearing it was revealed that after the c-section a piece of placenta had been left behind and Frances started losing blood.

Consultant anaesthetist Dr David Bogod told the hearing today that none of the medics on duty at the time knew who was in charge.

He said: “I’ve been looking into this case for three and a half years and I can’t work out who the on-duty consultant anaesthetist was.

“Dr Azeeez didn’t know and nor did Sarah Woodward. It looks from the rota like it was Dr Cornish but he says it wasn’t him.”

He added whoever was responsible was not informed when blood loss reached 1.7 litres – the point when according to trust policy they should have been told for at least three hours.

The inquest also heard from senior midwife Sarah Woodward who took an active role in treating the bleeding.

She agreed note taking from the point the haemorrhage was found onwards was “woefully inadequate”.

She also told the hearing how Dr Azeez failed to respond to an emergency message for ten minutes, leaving other staff to take on his crucial role.

Dr Azeez’s role included contacting the on-duty consultant if Frances’s condition was serious.

However, despite Frances being rushed to theatre for major surgery, this was not done.

On Wednesday Dr Gabriella Gray, who removed the 2.5 inch piece of placenta, told the hearing it was not difficult to find or remove and there was no reason why it was not initially spotted.

She also agreed notes of fluids administered and vital readings were severely lacking in detail.

Neil Sheldon, representing the family, had suggested Dr Azeez underestimated the blood loss by more than half, when he took over from Dr Gray.

It was previously reported that Mrs Cappuccini wanted to have a caesarean with her second child after she had a traumatic experience with the birth of her first son.

When she was taken to Tunbridge Wells Hospital, she was told not to make a decision based on “pain or fear”.

Giving evidence at the inquest Mr Cappuccini said the midwives had “almost a smirk across their face almost laughing” when the couple told them Mrs Cappuccini needed a caesarean.

Following their advice, Mrs Cappuccini endured a gruelling 12 hour labour before she was rushed for an caesarean at 8.30am the next morning.

The inquest previously heard how when the new mum was feeding her newborn son for the first time she felt blood “flowing between her legs” and was rushed into surgery.

She was one of the greatest people I am ever likely to meet in my life

Tom Cappuccini

Mr Cappuccini told the hearing: “I had the opportunity to kiss her and tell how much I loved her.

“She said I love you and if anything happens make sure you look after the boys.”

Following the surgery Mr Cappuccini was told a piece of placenta which was described as “raggedy” was found in her uterine cavity.

She was rushed to an Intensive Care Unit when she failed to come around from the general anaesthetic.

Appearing emotional in court, Mr Cappuccini said: “I was told that I could see her when she was stable in the ICU but I never got the chance.”

Pathologist Sebastian Lucas, who performed a post mortem examination at St Thomas Hospital in central London, said Mrs Cappuccini died of cardiac arrest.

“That was done under general anaesthetic and the problems happened when that procedure had finished when she was recovering from General anaesthesia and it’s from that time that things went awry.

“It looks as though she suffered respiratory arrest which led to multi organ problems and ultimately her death.”

He also said she had lost up to 50 per cent of her blood.

The inquest was originally halted in 2014 when it became apparent that criminal charges could be brought following the tragedy.

Maidstone and Tunbridge Wells NHS Trust made legal history by becoming the first NHS trust to face corporate manslaughter charges.

But the case was dismissed by a judge at the Inner London Crown Court in February 2016.

Dr Errol Cornish, the consultant anaesthetist who treated Mrs Cappuccini, was also told he had no case to answer with regards to gross negligence manslaughter charges against him.

Another doctor, Nadeem Azeez, also had charges against him dropped.

The inquest, which is due to last 10 days, continues.

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