Hospital failures led to woman's death after Caesarean procedure, coroner says
The death of a mother just hours after she gave birth to her second son was a result of "failures, inadequate diagnosis and treatment" at the hospital caring for her, a coroner said.
Frances Cappuccini, 30, died at Tunbridge Wells Hospital in Pembury, Kent, shortly after giving birth to her son Giacomo in October 2012.
A "bubbly, intelligent, beautiful" school teacher, Mrs Cappuccini suffered heavy bleeding after the Caesarean-section procedure.
She was anaesthetised and operated on but never regained consciousness, dying less than eight hours after her son was born.
Maidstone and Tunbridge Wells NHS Trust was condemned over standards after an inquest heard a piece of placenta was mistakenly left inside Mrs Cappuccini's uterus.
Coroner Roger Hatch said the Caesarean-section was not carried out with care and the failure to remove the placenta piece "led directly to the subsequent series of events which tragically ended in the death of Frances".
There were also mistakes in the way she was treated for breathing difficulties and how staff were supervised.
Mrs Cappuccini's husband Tom was in court to hear Mr Hatch deliver his conclusions at the end of the 10-day inquest.
Her family said that while nothing could "heal the pain" of their loss, after a four-year fight "the truth is acknowledged".
The inquest at Gravesend Old Town Hall in Kent heard Mrs Cappuccini had been terrified of having her second child because of difficulties during the birth of her first son.
She had chosen to have an elective Caesarean section birth on October 10 but went into labour two days before and was admitted to the Tunbridge Wells Hospital.
After a 12-hour labour, she finally had the Caesarean procedure, giving birth to Giacomo at 8.28am on October 9.
Suggestions she may have been pressured into having a natural birth were dismissed by the coroner.
After the birth, she began to bleed heavily and was rushed into emergency surgery before eventually going into cardiac arrest and dying at 4.20pm.
Dr Dib Datta, a consultant obstetrician and gynaecologist brought in to provide a report on the case, called the overlooking of the placenta a "fundamental failure of care".
Mrs Cappuccini lost 2.3 litres (more than four pints) of blood after the birth but the inquest heard there was no adequate fluid replacement plan in place.
The correct staff were not told of her haemorrhage and note-taking during her treatment was described as "inadequate".
Doctors also missed symptoms of sepsis and possibly a kidney injury, and the coroner said the premature removal of a breathing tube and a delay in its reinsertion also contributed to the emergency.
Mr Hatch said anaesthetist Dr Nadeem Azeez, who had the main responsibility for Mrs Cappuccini's care, should have been supervised better after being involved in a similar situation before.
The trust and another doctor, Errol Cornish, were accused of manslaughter over Mrs Cappuccini's death last year but the trial against them collapsed when a judge ordered their acquittal.
Prosecutors alleged Dr Azeez had committed a catalogue of "very great failures" which left Mrs Cappuccini unable to breathe properly after surgery and said he too would have faced charges of manslaughter if he had not returned to his native Pakistan.
Speaking on behalf of the family after the inquest, solicitor Kate Rohde said: "Frankie was a wonderful wife, mother, daughter and sister. She was bubbly, intelligent, beautiful, loving and much-loved.
"Failures of Maidstone and Tunbridge Wells NHS Trust and those employed by the trust cost Frankie her life. Nothing can heal that pain.
"At least today, after over four years, the truth is acknowledged."
The trust offered its "deepest sympathies" to Mrs Cappuccini's family and said it recognised it had "fallen short" in areas of her care.
As a result of her death, there have been changes to improve patient safety, it said, and it promised to consider the inquest's evidence to "ensure that any necessary changes which have not already been made are fully addressed."