Hospital Failures Blamed for Mother’s Death Hours after Caesarean Birth

‘Failures cost Frankie her life, nothing can heal that pain’: Husband welcomes ‘truth’ after coroner blames hospital errors for death of primary school teacher, 30, after a botched emergency C-section.

'Failures cost Frankie her life, nothing can heal that pain': Husband welcomes 'truth' after coroner blames hospital errors for death of primary school teacher, 30, after a botched emergency C-section. Picture copyright Press Association

A healthy young mother suffered catastrophic blood loss as she fed her newborn baby for the first time and died hours later because of ‘failures, inadequate diagnosis and treatment’ by doctors, a coroner ruled today.

Frances Cappuccini, 30, died at Tunbridge Wells Hospital in Pembury, Kent, shortly after giving birth to her second son, Giacomo, by Caesearean section.

The school teacher, nicknamed ‘Mrs Coffee’ by pupils because of her surname, suffered heavy bleeding, went into cardiac arrest and died at 4.20pm on October 9 2012.

Coroner Roger Hatch has delivered a damning assessment of the unacceptable hospital failures she suffered before her death.

Today Mr Cappuccini was in court with Frances’ parents at the end of the 10-day inquest and said in a statement: ‘Failures of Maidstone and Tunbridge Wells NHS Trust and those employed by the Trust cost Frankie her life. Nothing can heal that pain’.

She was cradling her newborn who was feeding for the first time when she felt a ‘gush of blood’ caused by a piece of placenta left behind after the c-section and lost four pints of blood – almost half the amount in her body.

Frances never woke from emergency surgery to stop the bleeding having told her husband Tom: ‘I love you – if anything happens just make sure you look after the boys.’

Speaking on behalf of the family solicitor Kate Rohde said today: ‘Frankie was a wonderful wife, mother, daughter and sister. She was bubbly, intelligent, beautiful, loving and much loved.

‘At least today, after over four years, the truth is acknowledged.’

Mrs Cappuccini was left waiting for potentially life saving drugs and a doctor probably removed her ventilation tube before she was able to breathe unaided, the inquest heard.

In January 2015 Maidstone and Tunbridge Wells NHS Trust was cleared of corporate manslaughter for her death and charges of gross negligence were dropped against anaesthetist Errol Cornish.

Dr Nadeem Azeez fled the country but charges against him were later dropped.

But four and half years after her death senior coroner Roger Hatch today ruled her death was the result of hospital failures following a two-week hearing at Gravesend Old Town Hall.

He said: ‘As a result of my findings I propose to record that the death of Frances Cappuccini was a result of failures and inadequate diagnosis and treatment of her at Tunbridge Wells Hospital on October 8 and 9 2012.’

He said expert evidence revealed she was likely suffering from sepsis and kidney injury from when she first arrived at hospital on October 8 – something which doctors consistently failed to diagnose or treat.

Doctor shouldn’t have been left unsupervised, coroner says

Coroner Roger Hatch cited a ‘failure with extubating’ after surgery and a subsequent delay in re-intubating by anaesthetist Dr Nadeem Azeez as a factor which led to the emergency situation – after it was revealed she may have not been breathing properly following an emergency operation to stem the haemorrhage.

He refused to accept evidence from Dr Azeez claiming she was ‘breathing, moving her arms and responding’ after the anaesthetic.

He also said Dr Azeez was involved in a similar incident previously and should have been under ‘proper supervision on October 9.’

An international arrest warrant was issued for Dr Azeez, who fled to his native Pakistan before the charges were eventually dropped.

In a statement heard on Monday, Dr Azeez sent his condolences to Mrs Cappuccini’s family, adding: ‘Unfortunately my best was not good enough to prevent her tragic death.’

He revealed he had suffered from ‘depression, insomnia and flashbacks’ and said he had decided to relinquish his registration as a doctor.

The inquest heard he had last provided a statement in February 2014 and had not been contactable since.

But when she arrived at hospital in October 8 in spontaneous labour doctors and nurses encouraged her to try for a natural birth.

She endured 12 hours of gruelling labour before finally being rushed for a c section.

Frances was cradling her newborn who was feeding for the first time when she felt a ‘gush of blood’.

She was eventually taken for an emergency procedure to stop the bleeding – where doctors found a ‘raggedy’ piece of placenta in her uterine cavity.

Sadly the mum never came around from the general anaesthetic and died just hours after the birth of son.

In his conclusions the coroner said the Caesarean section ‘was not carried out with care’ and the piece of placenta should not have been left behind.

‘The result of this failure led directly to the subsequent series of events which tragically ended in the death of Frances Cappuccini,’ he added.

He also criticised the management of fluid levels and said the treatment of a post-partum haemorrhage which was not managed in accordance with the trust’s protocols.

He said he did not think Frances was pressured into trying for a natural birth, although evidence from her husband said she had arrived at hospital ‘certain’ she wanted an immediate Caesarean.

The family declined to comment on whether they had negotiated a compensation settlement with the Trust.

A Trust spokesman said: ‘Maidstone and Tunbridge Wells NHS Trust wishes to extend its deepest sympathies to the family of Frances Cappuccini.

‘Patient safety remains of paramount importance to the Trust. The Trust has however recognised from the start that there were aspects of Frances’ care what fell short of the standards the Trust would expect and we wish once again to sincerely apologise to the family for this.

‘As a first result of Frances’ tragic death, the trust has made a number of changes to its processes that have further improved patient safety and experience.

‘The trust will carefully consider all of the evidence heard at the inquest to ensure that any necessary changes which have not already been made are fully addressed.’

Consultant anaesthetist Dr Errol Cornish told an inquest into her death that stimulator drugs were not available to him in the operating theatre and precious minutes were wasted waiting for them.

It took five minutes for the first stimulator to arrive but when that failed to work, there was another delay of five minutes until the second dose was delivered.

Dr Cornish explained that the drugs were needed because Mrs Cappuccini was not breathing and the nerve stimulator would bring her around.

The inquest, at Gravesend Old Town Hall in Kent, also heard how Dr Cornish left an operation to rush to the schoolteacher’s aid after Dr Nadeem Azeez failed to rouse her.

The tragic death of ‘Mrs Coffee’ and her family’s fight for justice

October 2012: Teacher Frances Cappuccini arrived at Tunbridge Wells Hospital in Kent to give birth to her second baby. She requested a Caesarean section but instead went through 12 hours of labour before finally being given surgery at 8.30am the next day. Mrs Cappucini died on October 9, 2012, just hours after giving birth to her second son Giacomo.

February 2014: The inquest into her death, held at West Kent Coroner’s Court in Sevenoaks, was halted when it became apparent that criminal charges could be brought following the tragedy.

March 2015: Kent Police revealed that two doctors and the NHS Trust would face charges. Maidstone and Tunbridge Wells NHS Trust made legal history by becoming the first NHS trust to face corporate manslaughter charges.

Dr Errol Cornish, the consultant anaesthetist who treated Mrs Cappuccini, had gross negligence manslaughter charges brought against him.

Another doctor Nadeem Azeez – who flew to Pakistan following the incident – was also charged.

January 2016: The case was dropped at the Inner Crown Court. Mr Justice Peter Coulson QC stopped the trial of South African-born consultant anaesthetist Dr Cornish and Maidstone and Tunbridge Wells NHS Trust, saying it would be ‘unsafe and unfair’ to go on.

January 2017: The inquest resumed this year, starting on January 3 and lasting 10 days, ending today.

He suggested that Dr Azeez, the anaesthetist in charge of the new mother, had removed her ventilation tube too early.

Dr Cornish told an inquest he has thought about what happened every day since then, and concluded that the teacher’s death was ‘not inevitable’.

He recalled how he decided in a ‘nanosecond’ to ask for ‘urgent help’ from an on-call anaesthetist and expected it to arrive in ‘maybe five minutes’.

But it took between 35 and 40 minutes to come – a delay that he agreed was ‘manifestly unsatisfactory’.

The white-haired South African and Dr Azeez both faced gross negligence manslaughter charges after Mrs Cappuccini’s death at Tunbridge Wells Hospital, Kent, in October 2012.

An international arrest warrant was issued for Dr Azeez, who fled to his native Pakistan before the charges were eventually dropped.

Dr Cornish told the inquest that Dr Azeez had told him Mrs Cappuccini had been ‘breathing well’ and had also moved her arms.

But he said in hindsight this was ‘extremely unlikely’ and said the anaesthetist had ‘lulled him into a false sense of security’.

He said: ‘I don’t think he told me half of the truth. He never told me about the blood loss. His recollection of Mrs Cappuccini breathing well and moving her arms – it just doesn’t fit with the rest of the picture.’

He agreed that Dr Azeez had probably taken the ventilation tube out before Mrs Cappuccini was able to breathe unaided.

The doctor – who has worked in around 20 UK hospitals – also revealed he had no idea he was supposed to have been supervising the junior anaesthetist that day.

He said he had never met him before and ‘did not have a clue’ about his abilities or experience.

The senior doctor also said he had to leave a patient on the operating table to help Dr Azeez, something he had ‘never done’ in 20 years as an anaesthetist.

He said: ‘It goes against many years of my training to leave my patients. It was a very traumatic decision to have to make.’

Yet he described Dr Azeez’s demeanour as ‘quietly silent’, adding: ‘He was calmish. He did not appear agitated. He didn’t seem anxious or worried.’

The senior anaesthetist told the inquest that he had been troubled by the teacher’s death ever since.

He said: ‘Not one single day has gone through my life when I haven’t gone through every aspect of this unfortunate episode. Every single day I have thought about it and wished it had gone differently.

‘My family and colleagues will confirm to you that every single day I go through this single case and ask, ‘was this the inevitable outcome?’ and the answer I come to is ‘no’. I don’t want to sound pompous or arrogant, I say that with humility.’


Source: Mail on Sunday