Frances Cappuccini

31st March 2017 

PRIVATE & CONFIDENTIAL 
Mr Roger Hatch 
North West Kent Coroners Officers Office 
The Old Town Hall  
High Street  
Gravesend  
DA11 0AZ 

Sent via email & post: NWKCoroner@kent.gov.uk  

Dear Mr Hatch 

Glenn Douglas 
Chief Executive 
Maidstone and Tunbridge Wells NHS Trust 
Maidstone Hospital 
Hermitage Lane 
Maidstone, ME16 9QQ 

Telephone: 01622 226419 

E-mail:  

Re:  Regulation  28  Report  to  Prevent  Future  Deaths  following  the  inquest  of  Frances 

Cappuccini who died at Maidstone Hospital on 12 October 2012. 

I am writing to respond to the concerns you raised during your investigation into the death of Frances 
Cappuccini,  and  to  explain  the  actions  that  Maidstone  and  Tunbridge  Wells  NHS  Trust  has  taken  in 
order to address those concerns.  

1)  What  action  is  taken  to  check  and  ensure  no  part  of  the  placenta  remains  following  a 

caesarean section delivery? 

The standard practice for checking full removal of the placenta during a caesarean section delivery is 
as follows: 

The Obstetrician performing the caesarean section inspects the uterine cavity and swabs it out prior to 
closure.  

The  Midwife  inspects  the  placenta  itself  once  removed  –  noting  its  appearance  in  the  healthcare 
records – and determines if it looks intact. Each placenta is different in terms of shape and size, which 
makes  this  a  challenging  task,  but  if  the  Midwife  has  any  concerns  regarding  the  appearance  of  the 
placenta  these  are  immediately  escalated  to  the  Obstetrician  conducting  the  surgery  for  further 
investigation and exploration of the uterine cavity. 

Once the caesarean section is completed, patients are initially monitored in Recovery before they are 
transferred to the Ward. Observations and vaginal blood loss are monitored closely and recorded in the 
healthcare records. Patients with significant blood loss (1500mls or above) remain on the Delivery Suite 
until their Haemoglobin (HB) is rechecked and observations remain stable. HB is a protein in red blood 
cells that carries oxygen throughout the body – by monitoring the level of HB we can quickly identify a 
lower level which might indicate complications that need to be investigated. By performing these checks 

Trust Headquarters: Maidstone Hospital, Hermitage Lane, Maidstone, Kent ME16 9QQ 
Telephone: 01622 729000/01892 823535    Fax: 01622 226416 

   Chief Executive: Glenn Douglas 

 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 immediately after the surgery this affords patients prompt access to Obstetric and Anaesthetic input if 
needed.   

We acknowledge, with regret, that this process was not successfully followed in Mrs Cappuccini’s case, 
however  in  the  intervening  years  since this  tragic  incident  all  of  our Obstetricians  and  Midwives  have 
completed  several  rounds  of  annual  training  (theoretical  and  practical)  to  ensure  that  they  are  as 
qualified and experienced as possible to ensure better outcomes in the future. 

Post-Partum haemorrhage (PPH) is a common occurrence in child birth, however due to the robustness 
of  our  processes  and the  additional  training  and  support  provided  to  staff,  our  outcomes  are  positive. 
Just  three-weeks  ago  in  our  weekly  Trust-wide  newsletter  I  was  able  to  praise  the  hard  work  of  the 
entire  team  involved  in  providing  care  to  a  woman  in  our  care  which  ultimately  saved  her  life.  The 
woman had suffered significant PPH after the caesarean section delivery of her baby but the volumes 
of  blood  loss  were  higher  and  over  a  more  prolonged  period  that  would  be  expected.  The 
professionalism  of  the  whole  team  involved  in  her  care  –  from  administrators,  Porters,  Haematology, 
Anaesthetics, Neonatal, Theatres, ITU, Obstetricians and Midwifery - meant that both mother and baby 
were  stabilised  and  discharged  home.  We  are  a  Trust  that  prides  itself  on  learning,  and  so  we  are 
preparing a report on the case to be shared internally and externally as an example of good practice.  

2)  The protocol for the management of post-partum haemorrhage was not followed by the 

medical staff. What procedures have been instigated to avoid this happening again. 

We ensure that all staff involved in providing care to patients who are at risk of suffering a Post-Partum 
haemorrhage  (PPH)  have  read  the  Post-Partum  Haemorrhage  Protocol,  and  they  sign  a  compliance 
slip to confirm this which is recorded within the department.  

Although all staff have read the protocol, we find that the most effective  way to ensure that protocols 
are followed  is  to  imbed  them  in  the  day-to-day  practice  of  our  staff,  so the  required  action  becomes 
‘second nature’. 

The  PROMPT  method  of  training  (Practical  Obstetric  Multi-Professional  Training),  which  is  a  training 
programme  run  in  maternity  units  across  the  country,  incorporates  the  management  of  a  range  of 
Obstetric emergency situations with interactive drills and workshops to provide 'hands on' experience of 
practical  skills  and  decision-making.  The  components  of  team  working,  including  training  for 
communication  in  an  emergency,  feature  throughout  the  course.  In  the  training  sessions,  which  are 
attended by multidisciplinary groups of staff, each member of staff plays the role in the training scenario 
that they would play in a real situation. 

PROMPT training supports the development of the technical skills required in an emergency and also 
the  development  of  non-technical  skills,  such  as  effective  communication,  calling  for  help  effectively, 
team working, making the best use of the resources available, and delegation. The training is modified 

Trust Headquarters: Maidstone Hospital, Hermitage Lane, Maidstone, Kent ME16 9QQ 
Telephone: 01622 729000/01892 823535    Fax: 01622 226416 

   Chief Executive: Glenn Douglas 

 
 
 
 
 
 
 
 
 
 
 
 to  target  any  trends that  have  been  identified  in incident  analysis.  The  Anaesthetic  scenarios that  we 
use are varied from year to year so that they are relevant and tailored to the particular training needs 
identified. The scenarios we use include the types of problems that were encountered in the care of Mrs 
Cappuccini, and examples of the training scenarios are enclosed. 

All  Obstetricians,  Midwives,  Operating  Theatre  Practitioners  and  Anaesthetists  who  have  a  regular 
commitment  to  the  Delivery  Suite  are  required  to  attend  mandatory  PROMPT  training  annually.  The 
relevant policies and guidelines are discussed as part of the training. Staff are reminded of any recent 
changes  or  updates  to  policies  and  guidelines  and  they  are  provided  with  further  information  about 
those changes. The attendance at training is recorded centrally and reviewed at annual appraisal and 
as staff approach the expiration date of their training, they and their managers receive a reminder via 
NHS email from our Learning and Development team to complete the training.  

Within the Obstetric department, massive PPH is reviewed at the weekly risk review and staff receive 
regular  feedback  and  guidance  on  best  practice  at  monthly  Clinical  Governance  sessions,  through 
doctors’ newsletters and maternity risk updates. 

In  addition  to  the  PROMPT  training,  the  Trust  also  offers  high  fidelity  simulation  training  for 
Obstetricians, Midwives and Operating Theatre Practitioners, and live emergency drills are run on the 
Delivery Suite when acuity allows. An example of this training is enclosed. 

On  22  March  2017  we  also  ran  a  joint  Clinical  Governance  session  with  Obstetrics  and  Anaesthesia 
and Mrs Cappuccini’s case (including inquest outcome and department reflections) was presented to a 
cross-section  of  staff  –  Consultants,  Junior  Doctors,  Nurses,  Midwives  and  Operating  Theatre 
Practitioners.  The  session  was  well  received  and  promoted  much  discussion  and  reflection,  with 
suggestions for best practice shared across the two Directorates.  

We  are  always  seeking  to  improve  our  service  and  minimise  patient  harm,  and  to  that  end  we 
constantly review our processes, training and documentation.  In light of the potential issues regarding 
drug  use  in  PPH  cases,  our  Pharmacy  team  have  created  a  new  guidance  document  for  staff  (copy 
enclosed). The Obstetric department is also reviewing fluid replacement at PPH, and undertakes yearly 
audits  regarding  PPH  documentation  including  the  regular  review  of  the  PPH  Proforma  to  ensure  it 
meets  the  needs  of  staff  in  the  time  critical  situations  they  work  in.  The  latest  version  of  the  PPH 
Proforma, which includes a new section for recording fluid input and output in theatre, is enclosed for 
your information. 

Trust Headquarters: Maidstone Hospital, Hermitage Lane, Maidstone, Kent ME16 9QQ 
Telephone: 01622 729000/01892 823535    Fax: 01622 226416 

   Chief Executive: Glenn Douglas 

 
 
 
 
 
 
 
 
 
 
 
 3)  Supervision  -  What  action  has  been  taken  to  ensure  that  staff  grade  anaesthetists  are 
supervised  and  that  both  the  staff  grade  and  supervisor  are  provided  details  of  the 
respective identities of the parties involved? 

All Anaesthetists have an electronic rota app on their phones and can identify who is the staff grade on 
for Labour Ward and who is the consultant covering.  

The rota has a simple, easy to understand format which shows that during day time hours Monday to 
Friday  the  staff grades  are  supervised  by  the  Consultant  Anaesthetist  covering  the  Labour Ward  and 
out of hours by the Consultant Anaesthetist on call. There is a policy within the department that in the 
unlikely event that the consultant covering Labour Ward is not contactable then the junior staff are to 
phone  an  alternative  consultant  -  this  would  be  the  intensivist  on  call,  the  Anaesthetist  or  intensivist 
covering Maidstone hospital and failing that, the Clinical Director.  

All staff grade and trainee Anaesthetists understand that they are in supervised roles, as this is detailed 
within  their  job  descriptions  and  in  their  induction  packs.  This  information  is  also  included  within  the 
induction packs for locum staff so they are aware of supervision arrangements and how to contact key 
personnel in an emergency. 

4)  What steps have been taken to avoid there being delays in a request for urgent help for 

an intensivist/anaesthetist. 

There  is  now  a  Consultant  Anaesthetist  who  exclusively  provides  cover  for  the  elective  caesarean 
section  list.  This  means  that  the  Consultant  Anaesthetist  on  duty  for  the  Delivery  Suite  has  no  other 
duties and is free to attend emergencies. Consultants are on site between 8am-6pm and on call outside 
of these hours. 

The  Anaesthetic  and  Obstetric  departments,  as  well  as  switchboard,  have  access  to  a  real-time 
electronic rota for the Anaesthetic department. There is also a weekly paper rota kept on Delivery Suite, 
and  consultants  add  their  name  and  bleep  number  to  the  whiteboard  in  the  Labour  Ward  handover 
room.  Additionally,  the  rotas  are  emailed  out  weekly  to  all  senior  staff  and  Delivery  Suite  Band  7 
Midwives.  

The rota now also incorporates the informal terms for the on-call Consultant Anaesthetist at Tunbridge 
Wells Hospital (‘the Man in Blue') and at Maidstone Hospital (“the Man in Red”) and all staff identified 
on the rota carry a mobile telephone and can be contacted either directly or via the Trust switchboard. 

Trust Headquarters: Maidstone Hospital, Hermitage Lane, Maidstone, Kent ME16 9QQ 
Telephone: 01622 729000/01892 823535    Fax: 01622 226416 

   Chief Executive: Glenn Douglas 

 
 
 
 
 
 
 
 
 
 
 
 
 I  would  also  add  that  the  PROMPT  training that  staff  working  in the  Delivery  Suite  undergo,  provides 
greater  assurance  that  staff  have  the  awareness  and  confidence  to  identify  the  situations  in  which 
assistance should be requested. 

5)  The inquest showed a number of examples of inadequate note keeping at the hospital – 

what actions have been taken to ensure this is not repeated in the future. 

Documentation training underpins core training for nurses, doctors and allied health practitioners at all 
levels  within  the  organisation.  All  staff  are  aware  of  the  importance  of  clear,  and  contemporaneous 
record  keeping  and  the  balance  that  must  be  struck  between  this  obligation  and  the  immediate  care 
and treatment to be provided to our patients. 

All staff undergo annual training which includes aspects of documentation within their departments, as 
well  as  the  Trust-wide  mandatory  Information  Governance  training.  The  Trust  Legal  Services 
department  also  runs  an  update  training  programme  which  delivers  training  at  departmental  Clinical 
Governance,  to  Foundation  Year  (FY)  1  and  FY2  doctor  training  days,  and  as  part  of  the  mandatory 
clinical update training and the nurse leadership training programme.  

We  continually  review  the  documentation  to  be  completed  in  addition  to  noting  in  the  healthcare 
records, to ensure they are easy to use in the highly-pressurised situations in which our staff work.  

We  also  undertake  regular  clinical  audits  on  documentation.  These  audits  can  be  local  to  each 
department - based on the challenges identified through previous audits or incident investigations - as 
well as the formal national audits we are obliged to conduct.  

I  want  to  thank  you  for  taking  the  time  to  bring  your  concerns  to  my  attention,  and  I  trust  that  this 
response is to your satisfaction. 

Yours sincerely 

Glenn Douglas 
Chief Executive 

Enc: 

1.  Example training materials 
2.  Pharmacy guidance 
3.  PPH Proforma 

Trust Headquarters: Maidstone Hospital, Hermitage Lane, Maidstone, Kent ME16 9QQ 
Telephone: 01622 729000/01892 823535    Fax: 01622 226416 

   Chief Executive: Glenn Douglas