Inadequacies on NHS maternity ward result in tragic death

The news this week that serious “failures, inadequate diagnosis and treatment” resulted in a woman’s death after childbirth underlines the tragic impact of some of the challenges faced by the NHS.

It has been reported that following a difficult first birth, Frances Cappunccini and her husband had initially elected for a caesarean section for the birth of their second son. However, it has been said that Obstetric staff at Tunbridge Wells Hospital in Pembury, Kent, persuaded the couple to allow labour to progress naturally. This change in management is said to have led to an emergency C-section on 9 October 2012 with disastrous consequences.

Mrs Cappunccini, who gave birth to a son, suffered heavy bleeding. She lost 2.3 litres of blood due to sections of placenta being mistakenly retained in her uterus before suffering a cardiac arrest. Doctors had to wait up to 10 minutes for vital drugs to treat her.

Not only were gross negligence manslaughter charges brought against two consultant anaesthetists, Dr Nadeem Azeez and Dr Errol Cornish, but Maidstone and Tunbridge Wells NHS Trust were charged with corporate manslaughter. This was the first prosecution case against a health body since the corporate manslaughter offence was introduced in 2008.

Trial judge Mr Justice Coulson acquitted the defendants, Dr Azeez and Dr Cornish, and the landmark case fell through due to a lack of evidence provided by the Prosecution.

However, during the trial it came to light that Dr Azeez had removed the mechanical ventilator air pipe at 12:15pm and replaced it with a manually operated face mask. Although it was apparent to other medical staff that Mrs Cappunccini was experiencing breathing difficulties, Dr Azeez did not call for help from the senior Dr Cornish until 1pm. It was found that Dr Cornish “stood nearby” and watched while Dr Azeez proceeded to ventilate manually.

Although Mrs Cappunccini was put back onto the mechanical ventilator, it was not until a member of staff alerted another consultant at 1:50pm. However, this was too late for Mrs Cappunccini.

At the inquest, Coroner Roger Hatch highlighted that the C-section “was not carried out with enough care” after identifying that neither Dr Azeez nor Dr Cornish held the necessary qualifications or training recommended by both the Royal College of Anaesthetists (RCA) and the NHS for anaesthetists caring for seriously ill patients.

Maidstone and Tunbridge Wells NHS Trust “recognised from the start that there were aspects of Frances’ care that fell short of standards that the trust would expect” and so admitted liability.
Settlement of an undisclosed figure has since been reached between the parties and the Trust have advised that they have since implemented changes to improve safety.

It is clear that the failure of crucial checks led to tragic consequences. As with many of these cases, these errors are fuelled by a lack of resources, training and experience, and this is leading to a growing number of claims for negligence in obstetrics and midwifery.

Devonshires has extensive experience of managing clinical negligence claims, particularly in the field of obstetrics and midwifery. If you or a member of your family has suffered as a result of negligent treatment

Devonshires can provide support and assistance. If you wish to talk with a member of our team, please get in touch with Karen Cathcart, a Solicitor in our Clinical Negligence Team.


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