“Please tell my story,” was one of the last things Latifa Maybury said to her family before she died on November 18 last year.

The 30-year-old had given birth to a beautiful baby boy just six months before, having no idea when she went into labour that she had stage four cancer which hadn’t been noticed throughout her pregnancy, despite regular prenatal checks and two visits to the emergency room.

It was only during childbirth that her obstetrician realised something was blocking her child’s passage into the world — it turned out to be a massive tumour in her colon. Latifa was given an emergency caesarean section and Khaleel was born a month prematurely on May 9.

Within days, his mother was told she was terminally ill and had to undergo surgery to have a colostomy bag fitted. A month after the birth, she begged hospital staff to explain how they could have missed all the signs.

“I don’t know if I’m going to live next week or live next year,” she sobbed, during a meeting with doctors and senior management at King Edward VII Memorial Hospital, which was recorded by her family.

The tape, heard by The Royal Gazette, makes for distressing listening. “I don’t know if I’m going to watch him growing up or not,” Latifa says of her newborn child. “Do you know what my body is going through?”

By the time of that meeting, on June 5, it was already too late to save Latifa. She lived another painful few months before passing away at KEMH with her family at her bedside.

Khaleel is now being brought up by his father Kemar Maybury and grandmother Keetha Lowe — both of whom are still struggling to come to terms with Latifa’s death and the fact that her son will grow up never knowing her.

The young mother’s family want to fulfil one of Latifa’s final wishes, by telling the public about her battle to beat cancer and the way, they allege, she was failed by Bermuda’s healthcare system.

Latifa was originally from Morocco — widely considered a developing country with inadequate medical facilities. Yet it was here in her adopted country, her husband’s homeland, that she was given “third world medical care”, according to her family.

Mr Maybury and Ms Lowe say their loved one was failed by emergency room doctors at KEMH, by her GP Shaina Kelly and by obstetrician Wendy Woods.

Their failures, the family allege, have been compounded by the way Bermuda Hospitals Board has since handled a complaint about the quality of Latifa’s care.

She was seen by emergency room doctors at KEMH before she conceived Khaleel, suffering from chronic constipation and “large amounts” of rectal bleeding. Doctors diagnosed haemorrhoids and gave Latifa suppositories and medication. She also had a stomach x-ray.

The hospitals board says the ER doctor who saw her was “concerned enough” by her symptoms to “direct her to her GP to have further diagnostic tests”. But the tests did not take place.

A BHB spokeswoman says the hospital faxed a “discharge sheet”, recommending a referral to a specialist and a test which screens for colon cancer, to Dr Kelly but the GP says she didn’t receive it and that Mrs Maybury didn’t come to her surgery for a follow-up visit. Discharge sheets from two later ER visits were also not received by Dr Kelly, the GP says.

This newspaper asked BHB to explain how the hospital confirms that dispatch sheets are received by GPs — but no response was forthcoming.

Mr Maybury believes his wife had cancer when the August 17 x-ray was done and doctors should have seen the signs on those images.

But Dr Woods says there was no sign. She told this newspaper: “Latifa was not a patient of mine at the time of her ER visit in August 2012. There was no report of an enlarged liver on the imaging study done at that time.

“After the delivery in May 2013, Latifa complained of upper abdominal pain — there was no complaint of upper abdominal pain during the pregnancy. Imaging studies were done at this time which showed an enlarged liver with suspicious appearing lesions.

“As this is not my area of specialty, the on-call hospitalist was consulted and Latifa was seen by the hospitalist. Subsequently, general surgeon Dr [Hermann] Thouet was consulted and became involved in the evaluation. He reviewed the imaging studies, including those from August 2012.

“Dr Daniel Stovell, head of radiology, reviewed the August 2012 images in May 2013 and, according to him and two other radiologists, there was no liver enlargement at that time.”

A BHB spokeswoman said the x-ray was read by one of BHB’s radiologists in August 2012 but she did not elaborate on the radiologist’s assessment of the images.

Mr Maybury says he and his wife would never have tried for a baby had cancer been diagnosed. It is believed hormonal changes in the body during pregnancy can accelerate the growth of the disease and the grieving widower thinks that is what happened to his wife.

He describes how after Khaleel was delivered and his wife was given an ultrasound, multiple malignant lesions were discovered on her liver.

More tests followed, showing the cancer had spread from another organ. On May 26, Dr Thouet found what is described in Latifa’s notes as a “large rectal obstructing mass” and she had surgery for a colostomy bag two days later. She told her mother-in-law: “Mom, they have broken my body.”

Mr Maybury and Ms Lowe point to two visits Latifa made to ER during her pregnancy — on January 18 and April 21, 2013 — when they say doctors should have spotted that she had cancer.

The two ER visits were prompted by Latifa suffering from anxiety, heart palpitations and numbness. The second visit arose after she collapsed at the Ag Show and her constipation and rectal bleeding was mentioned again, according to her hospital chart.

At the time, BHB’s policy was not to send discharge sheets to obstetricians for pregnant patients who visited ER. But the spokeswoman said that policy has been reviewed since hospital chiefs met with Mrs Maybury and her family.

“It is BHB policy to send GPs faxes of discharge sheets for every emergency visit,” she said. “It has never been policy for BHB to forward emergency department discharge sheets to specialists, including obstetricians.

“The expectation would be for the patient to raise this with the obstetrician and provide the discharge sheet if required. In the meeting with the family, BHB felt this was an opportunity to improve the coordination of care.

“Although Mrs Maybury did not mention her ongoing symptoms during these emergency visits, BHB does feel that there is value in obstetricians receiving ER discharge sheets going forward.”

Latifa’s hospital chart suggests she did mention her symptoms during the April 21 ER visit. It reads: “Long history of constipation ... PR [per rectum] bleed, says not passed urine today.”

The chart also records how her mother-in-law told doctors of her concern that Latifa had lost 14lbs during her pregnancy. The patient was sent home with laxatives and told to follow up with her obstetrician.

Dr Woods said she was aware of the April 21 ER visit, adding: “At her initial prenatal visit, Latifa gave a history of anxiety attacks for which she stated she was followed by her GP.

“I advised her to follow-up with her GP with respect to her anxiety attacks on at least two occasions. When I enquired if she had followed up with her GP as I recommended she had not.”

The obstetrician said Latifa verified during the June 5 meeting that “she had not told me of the rectal bleeding”

Dr Woods disputes that Latifa lost weight during the pregnancy. She says she put on only a couple of pounds — which isn’t normal — but did not lose any.

The obstetrician says when she saw Latifa for her 36 week check-up, shortly before she went into labour, she took the usual vaginal swabs to check for infection and did an external exam of her rectum, because the patient mentioned rectal bleeding. The doctor saw nothing untoward.

“The only thing that Latifa complained of during the pregnancy was constipation,” Dr Woods insisted. “I gave my usual advice in terms of increasing fibre and fluids.”

Ms Lowe says Latifa’s whole pregnancy was unusually painful and difficult and that should have prompted Dr Woods to look for any underlying issues — but the obstetrician says the patient did not relay those symptoms to her.

The devastating truth of what was happening to Latifa’s body went unnoticed until she went into early labour on May 9. Ms Lowe said: “My belief is that her body knew what she was going through and it was its way of getting Khaleel out of danger’s way.

“You had a newborn inside a stage four, metastatic cancer body, without any form of treatment whatsoever.”

Dr Woods agrees that she felt an obstruction during the pushing stage of labour, which she took to be hardened fecal matter, and ordered the c-section.

But the obstruction turned out to be something far worse — and Latifa and her husband, during what should have been one of the happiest occasions of their lives, were plunged into a nightmare.

Mr Maybury describes his wife’s agonising pain after the c-section and the intrusive, life-changing operations she had to endure in the days that followed — all while she should have been at home nursing her newborn child.

Watching him with his son, now 14 months old, is like seeing any adoring, new father. He nuzzles Khaleel’s neck, tickles him and laughs at the infant’s silly noises. But ask him about Latifa and his face changes in a second. His pain — and his anger — is palpable.

He doesn’t understand why the hospital won’t apologise, why it won’t offer any compensation for the horror he and his family have endured. And he says complaining to the quality and risk management team has just heaped on more frustration.

So far, the family says, BHB has not shared any findings from its internal investigations about what could have gone wrong. And since the family complained to the Ombudsman, there has been a complete shutdown on information.

Quality and risk manager vice president Preston Swan told Ms Lowe in an e-mail dated June 3 this year that “we are prepared to sit down and talk with you and your family again” once the Ombudsman’s inquiry is complete.

Ms Lowe replied by pointing out that more than a year had passed since Latifa’s cancer was diagnosed but BHB had failed to give any information on why it wasn’t picked up sooner.

“I am confident we and yourselves accept there were critical details which failed to meet the most basic medical standards,” she wrote.

“It seems your focus should be in recognising those factors, thereafter committing to raising standards to a level whereby such a tragedy never repeats inside the walls of KEMH ever again.”

In a separate e-mail to BHB chairman Jonathan Brewin, Ms Lowe said: “Bermuda’s only hospital appears more focused on investing in the expansion of its facility, rather than ensuring the highest levels of quality and efficiency in care and services. This was Latifa Maybury’s experience.

“Latifa suffered through a pregnancy which no human being, under efficient medical care, should have had to endure. [She] was repeatedly misdiagnosed, thus not treated for ‘terminal illness’ — stage four colorectal metastatic cancer — throughout her entire pregnancy, whereby two lives were left at risk. Latifa died under the worst of circumstances.”

Ms Lowe told Mr Brewin: “My effort to convey her story is not limited by emotion or grieving but through passion and respect for the sacrament of human right and dignity.

“Measures and systems within the medical framework failed — an invaluable life has been lost, an infant named Khaleel does not and will never know his mother [and] Kemar, a young husband has lost his wife.”

The BHB spokeswoman told this newspaper: “When BHB received the complaint from Mrs Maybury and her family, BHB recognised that it was an integrated health matter, so coordinated a meeting for the family to meet with both KEMH and community healthcare providers involved in the case.

“BHB wanted the family to have the opportunity to hear from all providers in an open forum. This meeting was arranged rather than starting with a root cause analysis in the interests of transparency, as root cause analysis documentation is usually only fully disclosed in a court of law as part of a legal case. A written summary of that meeting was sent to Mrs Maybury and her family, and all requested medical notes have been provided.

“Subsequently, the family requested the Ombudsman of Bermuda carry out an investigation and full disclosure has been provided to the Ombudsman as part of that legislated process.

“BHB agreed with the Ombudsman’s office that, before having further dialogue with the family, BHB would allow the Ombudsman to complete her investigation. This is to ensure that the Ombudsman’s investigation is in no way compromised.”

Khaleel will never get to meet his mother but she recorded a video for him shortly before she died, telling him how much she loved him and how sorry she was she wouldn’t be there as he grew up.

It will be many years before he understands why she died at such a young age — but his family hope that one day soon they will get some answers.