- Corporate manslaughter case against Maidstone and Tunbridge Wells Trust dismissed from court this morning
- Trial was first time an NHS organisation was prosecuted under corporate manslaughter laws
- Case related to death of a mother in trust’s care following emergency caesarean in 2012
- Read the full ruling from the judge
The first ever prosecution of an NHS trust for corporate manslaughter has been thrown out by a judge, after he found there was no case to answer.
Maidstone and Tunbridge Wells Trust was scheduled to begin its defence case at Inner London Crown Court next week, but Mr Justice Coulson has this morning instructed the jury to return a not guilty verdict.
He has also cleared Dr Errol Cornish, a consultant anaesthetist who was being prosecuted in tandem for gross negligence manslaughter.
In his ruling, the judge said the case against Dr Cornish was “as far removed from a gross negligence manslaughter case as it is possible to be”.
Both prosecutions related to the death of primary school teacher Frances Cappuccini, 30, who died in October 2012 after giving birth by emergency caesarean section at the trust’s Pembury Hospital.
Prosecutors alleged that Mrs Cappuccini was prematurely taken off mechanical ventilation by another anaesthetist, Dr Nadeem Azeez, who then used a face mask to “hand ventilate” the patient for 80 minutes, before mechanical ventilation was restored by a senior doctor. Dr Cornish was accused of failing to intervene and protect Mrs Cappuccini’s airway during some of this time.
But in a key section of his ruling, the judge found there was “no suggestion that the continuing use of the bag and mask over the relevant period was itself negligent or contrary to any guidance or advice governing the proper practice of anaesthetics”.
In relation to the corporate manslaughter charge, he found there was “no evidence at all” of a case against the trust arising out of the appointment process for the two anaesthetists. He described an expert’s assertion that Dr Cornish, who was a locum, should have been interviewed, as “perverse”.
In respect of alleged failings over Dr Azeez’s appraisals and professional development, the judge said: “Amongst other things, the appraisals made plain that Dr Azeez was undertaking extensive career professional development as a specialty doctor; that any complaints or criticisms raised in respect of him were minimal; and that the 360 degree appraisal in late 2010 was a significant success, indicating that a range of both his colleagues and his patients rated him highly.”
However, he found there was “evidence which is not tenuous” around the supervision of anaesthetists in the maternity and labour ward on the day of the incident.
He added: “This is a potential breach because there was a lack of clarity as to who Dr Azeez’s supervisor was.
“But in order for the jury to conclude that that was a gross breach, there would have had to have been some evidence that, in this case, Dr Azeez thought he needed a supervisor but did not call for one, or delayed in calling for one, because he did not know who that supervisor was…
“Gross breach could only be properly an issue for the jury if there was evidence that the lack of clarity about who the supervisor was created a significant problem in fact.”
The judge said the prosecution was wrong to suggest the case against the trust depended on gross failings by at least one of the doctors being established. He said: “Indeed it is perfectly possible to see ways in which, on other facts, the trust could have been liable under the 2007 act whilst Dr Cornish and Dr Azeez were not guilty of gross negligence manslaughter.”
The ruling also referred to arguments put forward by the trust’s legal team, which suggested the case should be thrown out because “the precise tier or precise individuals involved in the trust’s management had not been identified”.
The judge rejected this argument, saying that if there had been gross breaches, “there was plenty of evidence for the jury to conclude that the level of senior management responsible had been sufficiently identified in the evidence”.
He added: “It was either the CEO, or the medical director, or (if that was a different person) the clinical director… I express my surprise that this point was raised to support an application of no case to answer.”
Both the trust and Dr Cornish had pleaded not guilty to the respective charges against them. Dr Azeez was not charged as he had returned to Pakistan.
The case was the first time an NHS organisation had been charged under the Corporate Manslaughter and Corporate Homicide Act.
A statement issued on behalf of Maidstone and Tunbridge Wells Trust said: “The allegation of corporate manslaughter has been consistently denied by the trust, and has now also been comprehensively rejected by the court.
“The trust regrets that the Crown Prosecution Service saw fit to pursue the charge in the first place, given the additional distress this will have caused to all involved.”
It added that the trust wished to extend its “deepest sympathies to the family of Frances Cappuccini, who have approached this very difficult situation of a criminal trial into Frances’ tragic death with the utmost dignity throughout”.