The woman, "Mrs S", now a mother of two, was giving birth to her first child, a healthy son, in February 2013. A normal delivery was planned but it progressed to a medical induction, a non-reassuring fetal heart trace and then caesarean done with epidural anaesthesia.
Mrs S said she told the anaesthetist the surgery was hurting but he assured her she was feeling pressure, not pain. She heard questions about pain relief, to which the anaesthetist replied, "it would be over soon anyway".
Her husband, Mr S, said she repeatedly told him she was hurting. He asked the anaesthetist if she could have something for her pain, but Dr N told the woman he had given her enough pain relief.
Under questioning, however, Mr S said that although he caught Dr N's eye, he could not fully recall if he had verbalised the request for more pain relief as a whole sentence.
"The tribunal understands that Mrs S may have been experiencing pain; but the critical question is how this was verbalised or communicated. That pain may have been communicated by her to Mr S, her husband, or to [surgeon] Dr A or to ... [midwife Rosemary] Johnson or to ... [then-student midwife Birgit] Mitchell."
The question was how much of this was communicated to or understood by Dr N as the anaesthetist, the decision said.
"The tribunal accepts Dr N's evidence that, had there been communicated to him significant concerns about pain, he would have remembered these and he would have done something about them."
" ... there is insufficient evidence that any of the other persons in the surgery who may have heard Mrs S complain of pain conveyed this to Dr N in a sufficiently compelling way for him to have considered conferring with Mrs S to agree on a change to the analgesic plan."