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The death of a primary school teacher in childbirth five years ago will not be in vain after top doctors introduced a new safety test which will be named after her.
Frances Cappuccini, known as Frankie, who taught at Offham Primary School, suffered a fatal cardiac arrest several hours after giving birth by caesarean section in October 2012. She was only 30.
In 2017 a coronor ruled that Mrs Cappucini, from Sandown Road, West Malling, died as a result of a catalogue of failings by Tunbridge Wells hospital.
This week the Royal College of Anaesthetists has introduced a new audit tool to improve patient safety in anaesthesia based on the lessons learned from Mrs Cappuccini’s death, set to be known as the Cappuccini Test.
Her husband Tom described it as a "relief to know that there has been genuine learning from Frankie’s death".
The test will act as a checking system to ensure the proper supervision of trainee and senior associate specialist (SAS) anaesthetists.
SAS doctors are those who have trained in a medical speciality but have taken the non-consultant career path.
If they are identified from their rota as working alone they will be asked by the person carrying out the test who is supervising them and if they know how to get hold of that person.
The supervisor will then be called to double check they know the individual they are supposed to be supervising and what that individual is working on.
The Cappuccini Test is being incorporated into the standards set by the Royal College of Anaesthetists and into their hospital accreditation process.
One of the causes of Mrs Cappucinni's death was that staff didn't know who to turn to when the anaesthetist who was supervising her care, Dr Nadeem Azeez, failed to intubate her properly after things started to go wrong.
Mrs Cappuccini's husband Tom said: “It is a relief to know that there has been genuine learning from Frankie’s death.
"Patient safety has got to be paramount and learning from awful events such as Frankie’s case must be the only way forward.”
The changes have been advocated by David Bogod, an elected consultant member of the Royal College of Anaesthetists.
He said: “The NHS is dependent upon medical staff below the level of consultant for much of day-to-day patient care.
“It is a relief to know that there has been genuine learning from Frankie’s death..." - Mrs Cappuccini's husband Tom
"Prompt identification of and access to a supervising consultant is vital for patient safety, and failure of this process was a key factor in Frankie’s death.
"I am grateful to my colleagues at the Royal College and in Nottingham for their help in developing this simple audit tool to test for effective supervision, and particularly to the Cappuccini family for their support."
But he warned: "Inadequate consultant supervision is an issue that affects all areas of hospital care, and I hope to see the Cappuccini Test taken up by other medical specialities.”
Mrs Cappuccini suffered a major haemorrhage caused by a large piece of placenta left behind after the caesarean.
During surgery to correct this, she suffered inadequate ventilation which resulted in high levels of acid in her blood due to a lack of oxygen, causing her death.
