More than four years on from Frances Cappuccini’s death, the hospital trust responsible is no closer to answering crucial questions over her care.

The primary school teacher died after a caesarean at Tunbridge Wells Hospital in October 2012.

An inquest has now heard from a number of staff from Maidstone and Tunbridge Wells NHS Trust (MTW) and experts who 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 caesarian.

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.

On Friday Dr David Bogod, a consultant anaesthetist and expert on obstetrics, told the hearing Dr Azeez – who has since fled to Pakistan – failed to make sure Mrs Cappuccini’s airway was clear after the operation.

He said this check was the “bread and butter of anaesthetic practice” and the “most basic skill” Dr Azeez should have possessed.

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

He added that, despite investigating the case for three and a half years, he did not know who the on-call consultant anaesthetist was.

Mrs Cappuccini never came round after the critical operation.

Today, coroner Roger Hatch heard evidence from Dr Dib Datta – a consultant obstetrician who met with Mrs Cappuccini during her pregnancy.

Mrs Cappuccini’s husband Tom had previously told the inquest she had seen Dr Datta hours before she went into labour.

He said Dr Datta had advised against an epidural as it may mask the feeling of a uterine tear and told her to have a caesarian.

But Dr Datta told the inquest it was in fact his experienced colleague Dr Nada who met Mrs Cappuccini on the day in question.

He said he never advised against epidurals and still regularly informs staff not to do so, adding there was no medical reason why she would have been told to have a caesarean.

Neil Sheldon, representing the family, said: “Dr Nada should have documented a plan of what should have happened if Mrs Cappuccini went into spontaneous labour.

“He did not do that and the result was when she went into spontaneous labour later that day she turned up in the delivery suite with nothing in her records to tell staff what should happen.”

She was eventually denied a c-section but after 12 hours of agonising labour and slow progress, Mrs Cappuccini eventually underwent the procedure.

Dr Wai Wai Myit – who is currently in a remote part of Burma and has not been heard from in years – did the surgery and left behind a 2.5inch piece of placenta.

Mr Sheldon said: “We have heard evidence that it was not hard to find or remove the piece of placenta.

“This was a fundamental failure of care on the part of Dr Myit. We don’t know if she was in a hurry, distracted, or tired.”

Dr Datta told Mr Sheldon Dr Myit had worked for MTW for two years without incident.

Dr Datta agreed records of the type and volume of fluids administered by staff treating the haemorrhage were completely inadequate and at points non-existent.

He also acknowledged there was no evidence Dr Azeez was involved in any care plan and that the on-call consultant anaesthetist should have been at the very least informed of Mrs Cappuccini’s condition.

Mr Sheldon told Dr Datta: “Dr Azeez was a staff grade anaesthetist who should have had a named consultant overseeing him when he took Mrs Cappuccini into theatre, and here, four years after her death, we don’t know who that was.

He added: “If it’s right that those individuals who took Mrs Cappuccini into theatre did not know who to call in the event of an anaesthetic emergency, then that would be a failure of good clinical governance.”

Dr Errol Cornish, a consultant anaesthetist who was working in a nearby theatre at the time, was called in to assist Dr Azeez as Mrs Cappuccini had not woken up.

He said leaving his patient and her five-minute-old baby was an extremely difficult decision but the severity of the situation required him to do it.

When he arrived at 1pm Dr Azeez had been trying to rouse Mrs Cappuccini for half an hour.

Dr Cornish, who last year was cleared of gross negligence manslaughter, said not a day has gone by since her death in October 2012 when he hasn't thought about what could have been done differently.

He added Dr Azeez told him Mrs Cappuccini had moved her arms and was breathing well after he removed the tube at 12.30pm.

Dr Azeez's account, he said, does not add up and he has now come to the conclusion he only told him "half the truth."

Dr Cornish says it is his opininion the breathing tube was removed too early by Dr Azeez.

On numerous occasions it has been suggested Dr Cornish was the on-duty consultant anaesthetist who should have been overseeing Dr Azeez.

Dr Cornish denied this, saying he was not 100% sure who the on-duty consultant was but remembered a colleague mentioning it was Dr Paul Sigston.

He added he had never been told it was him and had never met Dr Azeez before.

It took 45 minutes from Dr Cornish arriving in theatre and calling for urgent assistance for help to arrive.

The inquest continues.