Frances Cappuccini inquest hears of anaesthetist call delay
Staff failed to contact an anaesthetic consultant for three hours after a woman gave birth by emergency Caesarean section, her inquest has heard.
Frances Cappuccini, 30, died after losing 2.3 litres of blood at Tunbridge Wells Hospital in Kent.
Obstetrics expert Dr David Bogod told the hearing the on-call consultant anaesthetist would be "essential".
He said he had looked into the case for three and a half years but still "couldn't work out" who that was.
Mrs Cappuccini, a primary school teacher, died several hours after giving birth to her second son Giacomo on 9 October 2012.
The inquest was told how after the surgery she had lost 1.7 litres of blood by 10:40 BST.
The family's lawyer Neil Sheldon asked Dr Bogod: "It would appear nobody contacted the on-call consultant anaesthetist until 13:30 - do you find that surprising?"
Dr Bogod replied: "What I find more surprising is I still don't know who the consultant anaesthetist was."
Earlier in the week Mrs Cappuccini's husband Tom told the inquest she endured a 12-hour labour after hospital staff refused an elective Caesarean section.
On Wednesday senior registrar Gabriella Gray said the patient lost 2.3 litres of blood and she was twice alerted to stop the bleeding.
Dr Gray accepted no consultant obstetrician was with Mrs Cappuccini for a time between the alerts but said she considered the mother had had a stable blood flow.
The patient received one litre of fluid replacement despite losing more than two litres of blood. Dr Gray said she had not departed from trust guidelines.
At a trial last January, a locum consultant anaesthetist Errol Cornish was cleared of gross negligence manslaughter and Maidstone and Tunbridge Wells NHS Trust was cleared of corporate manslaughter.
The inquest, at Gravesend Old Town Hall, resumes on Monday.