• The first corporate manslaughter prosecution of an NHS trust continues at Inner London Crown Court
  • Trial follows death of Frances Cappuccini after she gave birth by emergency caesarean section in October 2012 at Pembury Hospital
  • Anaesthetist was allowed to continue working after “inadequacies” were found in his care of another patient in March 2012

PATIENT SAFETY: An anaesthetist whose alleged errors form part of a landmark legal case against Maidstone and Tunbridge Wells Trust had previously made “straightforward and basic failings”, a court heard.

The first corporate manslaughter prosecution of an NHS trust is continuing at Inner London Crown Court this week.

Pembury hospital in tunbridge wells

Pembury Hospital in Tunbridge Wells

Frances Cappuccini dies in October 2012 at the trust’s Pembury Hospital

The trial follows the death of primary school teacher Frances Cappuccini, 30, after she gave birth by emergency caesarean section in October 2012 at the trust’s Pembury Hospital.

Yesterday the court was told of a previous incident involving Nadeem Azeez, whose failings are alleged to have contributed to the death of Ms Cappuccini.

Dr Azeez, who is not standing trial because he has returned to Pakistan, was allowed to continue working after “inadequacies” were found in his care of a patient who nearly died in March 2012, prosecutors said.

A report by consultant anaesthetist Cheron Bailey into Dr Azeez’s role in the March 2012 incident found “inadequacies in the anaesthetic care provided to the patient”, including poor post-operative “fluid resuscitation”, inadequate preoperative paperwork and failure to give intravenous antibiotics during surgery, the court heard.

The jury heard Dr Bailey spoke to Dr Azeez after reviewing the case, saying in the report: “We have gone through the case in detail and management of postpartum haemorrhage with particular reference to the case.

“[Dr Azeez] noted it was a very busy day on the labour ward then, but it was a very useful reflection for him and a good learning experience.”

Giving evidence on Monday, Dr Bailey was asked by prosecutor John Price QC: “It was your opinion, having looked at the records, that the drop in blood pressure might have been caused by the failure to fluid resuscitate?”

She said: “Yes.”

He asked: “These were straightforward and basic failings were they?”

She said: “Yes, but I would also like to point out that postpartum haemorrhage is not the sole responsibility of the anaesthetist, although I would expect him to lead the resuscitation.”

Dr Bailey also investigated Dr Azeez after Ms Cappuccini’s death for a serious incident review, the court heard.

In that report she said: “Dr Azeez needs a period of supervised practice and then further review (previous documented poor fluid resuscitation leading to critical incident).”

However, the jury heard that when the review was sent to the coroner and hospital management, the section in brackets was omitted.

Karen Carter-Woods, a trust manager who compiled the review, told the court on Monday she could not remember who had removed it.

The trust has denied the charges against it.

As part of the same case, consultant anaesthetist Errol Cornish pleaded not guilty to gross negligence manslaughter.

Last week, prosecutors said the trust had failed to ensure that Dr Cornish and Dr Azeez had the right qualifications and training and for their roles.

After her caesarean, Ms Cappuccini had required a general anaesthetic for a further procedure to remove residual tissue.

The procedure was performed successfully, but problems arose when she was taken off mechanical ventilation, the court heard. Prosecutors allege the doctors failed to ensure mechanical ventilation was restored once it became clear Ms Cappuccini was not becoming conscious or breathing properly.

It is the first time an NHS trust has been charged with corporate manslaughter since its introduction in 2008.

The trial continues.