A doctor who has since fled to Pakistan failed in fundamental aspects of his role, an inquest into the death of Frances Cappuccini has heard.

Dr Nadeem Azeez – who was the subject of an international arrest warrant last year – failed to make sure Mrs Cappuccini’s airway was clear following major surgery to treat a severe haemorrhage.

The 30-year-old Offham Primary School teacher later died after failing to come round from general anaesthetic.

Before she was rushed to emergency surgery she had delivered her son, Giacomo, by caesarean section, in October 2012.

At an earlier inquest hearing it was revealed that after the c-section a piece of placenta had been left behind, and Mrs Cappuccini started losing blood.

Giving evidence today at Gravesend Old Town Hall, Dr David Bogod, a consultant anaesthetist and expert on obstetrics, said making sure the airway was clear was the “bread and butter of anaesthetic practice” and the “most basic skill” Dr Azeez should have possessed.

He had earlier said mother-of-two Mrs Cappuccini was inadequately ventilated following the operation to remove the piece of placenta left in her uterus and the most likely cause of this was airway obstruction.

He also revealed the confusion around the system of appointing an on-duty consultant.

Dr Bogod said: "I've been looking into this case for three and a half years and I can't work out who the on-duty consultant anaesthetist was. Dr Azeeez didn't know and nor did Sarah Woodward. It looks from the rota like it was Dr Cornish but he says it wasn't him."

He added whoever was responsible was not informed when blood loss reached 1.7 litres — the point when according to trust policy they should have been told — at 10.10am and wasn't contacted until 1.30pm.

Dr Bogod also countered suggestions an epidural shouldn't have been administered to Mrs Cappuccini as it may mask the pain of a uterine tear.

He said that was a theory which was debunked several years ago and in fact it was common for women who, like Mrs Cappuccini, had previously undergone a caesarean to receive one if they were having a natural birth.

This morning the inquest also heard from senior midwife Sarah Woodward who took an active role in treating the bleed.

She agreed note taking from the point the haemorrhage was found onwards was “woefully inadequate.”

She also told the hearing how Dr Azeez failed to respond to an emergency message for 10 minutes, leaving other staff to take on his crucial role.

Dr Azeez’s role included contacting the on-duty consultant if Mrs Cappuccini’s condition was serious.

However, despite Mrs Cappuccini being rushed to theatre for major surgery, this was not done.

On Wednesday Dr Gabriella Gray, who removed the 2.5 inch piece of placenta, told the hearing it was not difficult to find or remove and there was no reason why it was not initially spotted.

She also agreed notes of fluids administered and vital readings were severely lacking in detail.

Neil Sheldon, representing the family, had suggested Dr Azeez underestimated the blood loss by more than half, when he took over from Dr Gray.

A statement written by Dr Azeez following Mrs Cappuccini’s death at Tunbridge Wells Hospital in October 2012 is due to be read to the court this afternoon.

The inquest continues.