A coroner has found a primary school teacher died as a result of a catalogue of failings by Tunbridge Wells hospital.

Frances Cappuccini suffered a fatal cardiac arrest several hours after giving birth by caesarean section in October 2012.

North West Kent coroner Roger Hatch is set to make recommendations under schedule 5, a power which suggests what action should be taken to prevent future deaths.

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A statement, issued by Mrs Cappuccini's family following the inquest, said: "Frankie was a wonderful wife, mother, daughter and sister. She was bubbly, intelligent, beautiful, loving and much loved.

"Failures of Maidstone and Tunbridge Wells NHS Trust and those employed by the Trust cost Frankie her life. Nothing can heal that pain.

"At least today, after over four years, the truth is acknowledged."

Video: The Family walk into Gravesend Town Hall for last day of the inquest

A 10-day inquest at Gravesend Town Hall heard from a number of staff from Maidstone and Tunbridge Wells NHS Trust (MTW) and experts.

The coroner heard from staff who said they were unable to identify the on-call consultant who should have been supervising Dr Nadeem Azeez.

The anaesthetist – who was the subject of an international arrest warrant last year – was responsible for mother-of-two Mrs Cappuccini during surgery on a major haemorrhage caused by a large piece of placenta left behind after a caesarean.

He should have been supervised following a strikingly similar incident seven months earlier.

Details of Dr Azeez’s previous error had been removed from Maidstone and Tunbridge Wells NHS Trust’s (MTW) report presented to the coroner. No one from the trust could say why or by who.

Mr Hatch was also told there was no reason why Dr Wai Wai Myit – who performed the botched c-section but was unavailable to give evidence due to being in a remote part of Burma – did not spot the 2.5inch piece of placenta.

The “fundamental error” set off a tragic chain of events which led to Mrs Cappuccini’s death.

Video: Frances Cappuccini's family make a statement outside court

The 30-year-old Offham Primary School teacher lost up to half her blood as a result of the procedure, although this was not the direct cause of her death.

Dr David Bogod, a consultant anaesthetist and expert on obstetrics, told the hearing Dr Azeez – who has since returned to Pakistan – failed to make sure Mrs Cappuccini’s airway was clear after the operation and called the check the "bread and butter of anesthetic practice."

Dr Bogod said Mrs Cappuccini died due to inadequate ventilation most likely caused by the airway obstruction.

The inquest heard Dr Azeez most probably removed Mrs Cappuccini's breathing tube too early.

The inquest resumed on January 3, when it was heard Mrs Cappuccini was persuaded by doctors to opt for a natural birth while she was in labour, despite having asked for a C-section.

The decision was later reversed by medics but Mr Hatch ruled she was not pressured over what mode of birth to go for.

In addition to the failings surrounding Dr Azeez’s involvement Mr Hatch said it remains unclear who should have been supervising him.

Dr Errol Cornish – who was cleared of gross negligence manslaughter last year – was initially in the frame but having heard evidence from him Mr Hatch accepted he had not been told it was his job. Despite this the 69-year-old anaesthetist left his patient to rush to Dr Azeez’s aid.

Mr Hatch did not accept Dr Azeez’s written account Mrs Cappuccini had been breathing well and moving when the tube was removed.

He said the haemorrhage, which saw Mrs Cappuccini lose half her blood, was not managed according to MTW’s policy; there was no adequate fluid replacement plan, note taking was “woefully inadequate” and the on-call consultant anaesthetist was not informed about the bleed.

Furthermore, none of the treatment was covered by antibiotics despite there being substantial evidence she was suffering from sepsis or a kidney injury.

He concluded: “The death of Frances Cappuccini was a result of failures, inadequate diagnosis and treatment.”

A statement released by Maidstone and Tunbridge Wells NHS Trust, following the inquest, said a number of changes had been made following Mrs Cappuccini's death.

It said: "Patient safety remains of paramount importance to the Trust. The Trust has however recognised from the start that there were aspects of Frances' care that fell short of the standards that the Trust would expect and we wish to once again sincerely apologise to the family for this.

"The Trust will carefully consider all of the evidence heard at the inquest to ensure that any necessary changes which have not already been made are fully addressed."