Failures at Tunbridge Wells Hospital near Pembury led to the death of Frances Cappuccini, 30, as she gave birth to her second son by emergency caesarean in 2012.
An inquest at Gravesend Old Town Hall heard from coroner, Roger Hatch, that the caesarean was not carried out with enough care, and that her tragic death was the result of “failures, inadequate diagnoses and treatment”.
Mrs Cappuccini suffered a haemorrhage and heavy bleeding, but went into cardiac arrest. Doctors had to wait up to 10 minutes for vital drugs. The coroner said checks should have been made to ensure nothing was missed, after a piece of placenta was left in her womb.
The inquest previously heard Dr Nadeem Azeez, the doctor who had been caring for Mrs Cappuccini, had made a mistake seven months earlier.
This is a tragic case of a health care provider not learning from past mistakes in order to minimise future risks and see that medical negligence does not put further patients at risk.
In December, a review by health watchdog, the Care Quality Commission (CQC) revealed “system-wide” problems in NHS investigations into patient deaths. As a result, family members have been left in the dark about failures in care.
Under duty of candour guidelines, hospital trusts and medical staff therein must ensure that honest and transparent processes are in place that includes patients’ families when investigating causes of death.
More and more we are seeing that patient safety is at risk due to the immense workloads placed on health care professionals.
Increased pressures on the NHS will only add to the stress on the system and more tragedies like this are unfortunately more - not less - likely to happen for the foreseeable future.
Ian Cohen is a clinical negligence solicitor at Slater and Gordon Lawyers in Liverpool.
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