Minute by minute, the fatal errors

OCTOBER 8, 2012

8.30PM: Mrs Cappuccini’s waters break and her observations are recorded as normal. Medical staff persuade the cou - ple to discard their plan for a caesarean and instead wait to see if a natural birth is possible. They reluctantly agree.

9PM TO 7AM: Mrs Cappuccini is growing increasingly anxious. She is wor - ried that the labour is not progressing, tells a midwife she wants to be ‘safe’ and talks to staff about a caesarean. She is given pain relief and urged to wait for a natural delivery.

OCTOBER 9

7AM: Told that it could be another five hours until she is ready to give birth, the couple decide on a caesarean as originally planned.

7.30AM: Mrs Cappuccini is taken into theatre and given a spinal epidural. She is conscious as a caesareansection is carried out.

8.28AM: The operation appears to be a success and Giacomo is delivered weighing 7lb 15oz. But doctors have mistakenly left a piece of placenta in her womb which will soon cause her to start bleeding profusely. She is trans - ferred back to her room on the labour ward where she is able to breastfeed her son for the first time. Mr Cappuc - cini texts his parents a photo of mother and baby with the message ‘All is well’.

10AM: Mrs Cappuccini tells her hus - band she can feel a ‘flowing’ sensation and he finds she is bleeding heavily . He tells staff who discover she has lost 1.6 litres (nearly three pints) of blood. She begins to breathe heavily and vomit.

10.39AM: Mrs Cappuccini breastfeeds Giacomo for the second – and last – time.

11.20AM: She is now in the High Dependency Unit. An emergency buzzer sounds signalling she has lost even more blood and the decision is made to rush her into theatre. It is the last time her husband will see her alive. Mrs Cappuccini, who has never before had a generalanaes - thetic, is anaesthetised by Dr Nadeem Azeez. Dr Gabriella Gray discovers the residual placenta left inside her womb during the caesarean. It is removed via a non-surgical procedure. There was no need for the general anaesthetic.

12.20PM: Mrs Cappuccini is left in the care of Dr Azeez, whose job it now is to bring her around safely.

12.30PM: Dr Azeez notes she is showing signs of waking as she’s responding to vocal commands and has opened her eyes. Nurse Dawn Warboys hears Dr Azeez calling Mrs Cappuccini’s name and gently shaking her , but does not see or hear any response. Dr Azeez removes the tube that had been inserted to help her breathe but she fails to start breathing independently so he uses a face -mask and bag to

ventilate her manually. She does not respond. He starts to move her around and prop her up with cushions.

12.45PM: Dr Azeez administers a second dose of an agent used to counter the effects of the anaesthetic. When asked by Dr Gray if all is OK, he nods and appears calm – but there are still no signs of response from Mrs Cappuccini.

1PM: Rebecca Shaw, operating department practitioner, calls for help from consultant anaesthetist Dr Errol Cor - nish in a room next door . He asks for Mrs Cappuccini’s temperature to be taken and for a nerve stimulator to check the degree of paralysis. She has been off the ventilator for 30 minutes and is not breathing independently. At this stage, the prosecution claimed, Mrs Cappuccini is ‘effectively dying’.

1.20PM: It has been 50 minutes since the tube was removed and since Dr Azeez began using the face mask . Dr Cornish tells a colleague that they are trying to avoid having to re -insert the mechanical breathing tube. No alarms sound to indicate a problem, yet there is still no response from Mrs Cappuccini.

1.30PM: Dr Garth Sommerville arrives. He spots that the oxygen from the face mask appears to be entering the mother’s stomach instead of her lungs. He also notices the CO2 readings of the face mask do not appear on the monitor , indicating that the mask may not be properly applied. He directs Dr Azeez to step up ventilation efforts using a laryngeal mask. He leaves to scrub up but returns moments later to find his orders were not followed. Dr Raymond Chung, a senior doctor on call, is contacted and claims he ordered Dr Azeez to re-insert the breathing tube.

1.44PM: Blood test results reveal Mrs Cappuccini has a build up of acid in her blood caused by a lack of oxygen. Dr Chung arrives and takes over, ordering Dr Azeez to re-insert Mrs Cappuccini’s breathing tube. But this is not done for another 30 minutes.

2PM TO 2.15PM: Dr Azeez attempts to re-insert the breathing tube but fails. Dr Chung does it himself. Although Mrs Cappuccini’s oxygen saturation levels return to 100 per cent, it is too late. Mr Cappuccini is told that medical staff are waiting for his wife to come round.

2.45PM: Mrs Cappuccini is transferred to intensive care but there are no beds available, so she is left in an emergency recovery area on a ventilator . At this stage, Dr Elias Kavoor claimed no one realised she was in a critical state.

3.16PM: Mrs Cappuccini’s pulse and blood pressure drop.

3.17PM Her heart stops. Mr Cappuccini is informed as, for the next hour , medical staff try to save her.

4.20PM: Mrs Cappuccini is pronounced dead. The devastating news is broken to the family.