After four years, the truth at last
Family’s relief at coroner’s damning verdict on blunders that killed caesarean mother
A CATALOGUE of errors by doctors that cost a mother her life was condemned by a coroner yesterday.
Primary school teacher Frances Cappuccini, 30, died hours after the birth of her second son because bungling doctors messed up her caesarean, ignored procedures, and finally botched her anaesthetic, an inquest concluded.
The coroner questioned the honesty of one of those doctors – anaesthetist Dr Nadeem Azeez – and said he should not have been left alone with Mrs Cappuccini after nearly killing another mother months before.
In his damning verdict, senior coroner Roger Hatch ruled that medical staff’s failure to spot that she was suffering from sepsis contributed to her death.
He declared that the teacher died as a ‘result of the failures, inadequate diagnosis and treatment’ at Tunbridge Wells Hospital in Kent in 2012.
The disturbing findings came a year after a criminal trial collapsed and gross negligence manslaughter charges were dropped against Maidstone and Tunbridge Wells NHS Trust, Dr Azeez and another doctor. Dr Azeez is now living in his native Pakistan after fleeing the UK before he was charged.
Mrs Cappuccini’s family blamed the death of a ‘ wonderful wife and mother’ on the hospital trust and its staff.
They said: ‘Nothing can heal that pain. At least today, after over four years, the truth is acknowledged.
‘Frankie was a wonderful wife, mother, daughter and sister. Failures of the Maidstone and Tunbridge Wells NHS Trust and those employed by the trust cost Frankie her life. Nothing can heal that pain.’
The mother-of-two had been ‘anxious and frightened’ after the traumatic birth of her first son and had been expecting and wanting a caesarean straight away after her waters broke in October 2012, the two-week inquest at Gravesend Old Town Hall heard.
However, she decided to try for a natural birth after speaking to midwives at the hospital and having an epidural.
Yet after a torturous 12-hour labour she had to have an emergency C-section anyway.
But surgeons botched the operation, leaving a chunk of placenta inside her which triggered a huge bleed as she started to breastfeed her newborn son Giacomo.
Mrs Cappuccini – affectionately known as Mrs Coffee by her young pupils – was taken into surgery so doctors could investigate. She told hospital staff: ‘Just save my life.’
The mother, described as ‘bubbly, intelligent, and beautiful’ by her family, also told her husband Tom: ‘If anything happens, look after the boys’. Doctors soon found the cause of the bleeding and removed the piece of placenta without needing to operate, but by this time Mrs Cappuccini had lost more than two litres of blood.
She did not wake up from the general anaesthetic and had a cardiac arrest on the operating table after blunders by Dr Azeez, who told her husband to ‘pray’ that his wife woke up.
The coroner yesterday outlined the key failures that ‘tragically ended in the death of Frances’, from the botched caesarean section, to the ‘inadequate’ supervision of Dr Azeez.
Concluding with a narrative verdict, he said Mrs Cappuccini had died from a combination of cardio-respiratory arrest, problems relating to general anaesthetic, the birth, sepsis and acute kidney injury. Mr Hatch also ordered the hospital trust to produce a comprehensive report on the action it has taken since the tragedy.
A spokesman for the NHS trust last night said ‘a number of changes’ had been made, adding: ‘The trust will carefully consider all of the evidence heard at the inquest to ensure any necessary changes which have not already been made are fully addressed.’
The Daily Mail launched its End the Sepsis Scandal campaign a year ago to raise awareness about the ‘silent killer’, which hits an estimated 200,000 people a year.
The condition occurs when a bacterial infection – such as septicaemia or blood poisoning – triggers a violent immune response in which the body attacks its own organs.