An Inquest has heard that the tragic death of Frances Cappuccini following an emergency C-section was a result of “failures, inadequate diagnosis and treatment” according to the Coroner hearing the case.
As we previously blogged Mrs Cappuccini suffered from heavy blood loss during a caesarean section, giving birth to her second child. At the Inquest a number of failures were identified in her treatment which are thought to have led to her death; including:
- A failure to carry out checks that would have identified a piece of placenta left in her womb;
- The Anaesthetist, Dr Nadeem Azeez removing a breathing tube too soon and failing to re-insert it;
- Vital drugs that should have been to hand in the theatre not being available, and delays in these being brought to theatre to try and save Mrs Cappuccini;
- Inadequate supervision of Dr Azeez, who had made similar mistakes in the past.
These failings were all avoidable and the overall tone of the Coroner’s verdict was that not enough care has been taken to treat Mrs Cappuccini.
Dr Cornish, the doctor brought in to try and save Mrs Cappuccini was previously charged with gross negligent manslaughter, but was acquitted on the basis that a Judge could not find evidence that he had done anything to contribute to her death. That same verdict also found that the Maidstone and Tunbridge Wells NHS Trust was not guilty of systemic failure that could allow it to be convicted of corporate manslaughter.
Dr Azeez returned to his native Pakistan not long after the death, and has therefore not been subject to any civil or criminal proceedings at this time, so it remains to be seen whether his conduct was so far removed from acceptable that it can be considered to be criminal.
We hope that all NHS Trusts can learn from this tragic accident and engage in the spirit of openness to ensure that the lessons can filter down and staff can avoid the simple but devastating errors that have occurred in this and other cases across the country.