A heavily pregnant mother was pressured into choosing what type of birth to have just hours before her tragic death, an inquest has heard.
The hearing resumed today into the death of Frances Cappuccini who passed away hours after giving birth at Tunbridge Wells Hospital, prompting a landmark court case.
The teacher, 30, suffered a heart attack following the delivery of her second son, Giacomo, by a caesarean section in October 2012.
Her widower Tom revealed to the inquest that his wife's last words to him were: "Just make sure if anything happens you look after the boys.”
The popular Offham Primary School teacher suffered severe bleeding and never regained consciousness after the surgery.
It was found she had high levels of acid in her blood due to a lack of oxygen and it was alleged the anaesthetists failed to re-intubate her quickly enough.
Today, at Gravesend Old Town Hall, a coroner resumed the inquest into Mrs Cappuccini's death. It was halted in 2014 when it became apparent criminal charges could be brought following the tragedy.
Mrs Cappuccini was adamant she wanted a cesarean section when she arrived at Tunbridge Wells Hospital in October 2012, however was persuaded by doctors to opt for a natural birth, according to her husband Tom.
Today, the first day of a 10-day inquest into her death – Mr Cappuccini told the Gravesend Old Town Hall hearing how after 12 hours of agonising labour and little progress the decision was finally made to allow his 30-year-old wife to undergo the procedure.
An epidural had already been administered, despite warnings from Mr Cappuccini that a consultant at Maidstone Hospital had explicitly told his school teacher wife the day before she should not undergo one due to possible liver issues.
Medical notes were checked by a surgeon – who is unavailable to give evidence as she is in a remote area of Burma and hasn’t been heard from in years – but no record of any such advice was found, despite both hospitals belonging to the same trust.
Mr Cappuccini also informed staff his wife had experienced severe bleeding following the birth of her first child Luca, three years previously at Farnborough Hospital.
During the procedure a "large piece of placenta" was left behind.
Following the c-section and the birth of her son Giacomo, now aged four, she again suffered extensive bleeding.
Mr Cappuccini wept as he recounted how he kissed his wife and told her he loved her before she was taken to the intensive care unit.
She responded: “I love you too. Just make sure if anything happens you look after the boys.” It was the last time he saw his wife alive.
He told the hearing: “Frankie was a bubbly, kind, caring and loving person. She had lots of friends and always listened to them and offered advice. She was loved by everyone.
“She was a great mother who always loved looking after Luca and used her experience as a teacher to give him a great start in life that Giacomo sadly missed out on.”
Pathologist Professor Sebastian Lucas told the inquest Mrs Cappuccini's death was due to complications related to anaesthetic.
She lost around half of her blood after the c-section.
But prof Lucas said while the haemorrhage was a contributing factor to her death it was not the cause.
He said it was likely Mrs Cappuccini died as a result of insufficient care and ventilation after coming round from general anaesthetic following surgery to address the haemorrhage.
Prof Lucas added the cause of the bleed – during which she lost 2.3 to three litres of blood – was a large piece of placenta left behind after the c-section.
Maidstone and Tunbridge Wells made legal history by becoming the first NHS trust to face corporate manslaughter charges.
The Trust was accused of failing to check the doctors were properly qualified, but the allegations were dismissed by a judge at the Inner London Crown Court in February 2016.
Dr Errol Cornish, the consultant anaesthetist who treated Mrs Cappuccini, was also told he had no case to answer with regards to gross negligence manslaughter charges against him.
Another doctor who treated her, Nadeem Azeez, was not on trial as he was no longer in the country.
However, the Trust admitted there were aspects of Mrs Cappuccini’s care that did not meet expected standards and issued an apology to her family.
The inquest, chaired by coroner Roger Hatch, is expected to last nine days.