On June 5 last year, June Wanza Mulupi walked into Surgeoderm Healthcare Limited, a private clinic in Nairobi, to have her breasts enlarged and firmed up.
She was 35 years old and a mother of three, considerably healthy, and looking forward to leaving the clinic within hours.
But that was not to be as, a few hours later, and despite assurances by the surgeons that she would be fine, she developed complications that killed her two days later, leaving behind a distraught husband and their three children.
Eight months after Ms Mulupi's shocking death, investigators have pointed accusing fingers at the three doctors who operated on her, as well as the management of Surgeoderm Healthcare Limited.
The Kenya Medical Practitioners and Dentists Board (KMPDB) found that Dr Martin Ajujo, who led the procedure, was still a trainee and was not licensed to conduct surgery without the supervision of a practising plastic surgeon.
A shareholder in the clinic, Dr Ajujo was supposed to work under the supervision of another shareholder, Prof Stanley Ominde Khainga, who is also the head of the plastic and reconstructive surgery department at the University of Nairobi.
Investigations into the matter also revealed that, although already graduated, the anaesthetist, Dr Evans Charana, did not have a private practice or locum licence from KMPDB. He also had no professional indemnity insurance as required by law.
At the time of the operation, Dr Ajujo was a plastic surgery and reconstructive registrar at Kenyatta National Hospital.
This means he was receiving training under a supervisor on his journey to becoming a plastic surgeon.
He was also a Nairobi County employee seconded to Mama Lucy Kibaki Hospital, but was on study leave.
The crux of the investigation revolved around how, despite not being allowed to conduct any surgery unsupervised, Dr Ajujo went ahead and listed himself as the operating surgeon on Ms Mulupi's admission papers at Surgeoderm.
Owing to the low number of plastic surgery patients at Kenyatta National Hospital, Prof Khainga had allowed Dr Ajujo to train in other facilities under his supervision, and that might explain how he ended up at Surgeoderm.
Dr Ajujo confessed to the KMPDB team that he took the notes in Ms Mulupi's file, and that there were no notes by Prof Khainga. Any error in Ms Mulupi's patient file was his, not Prof Khainga's, he added.
To make matters worse, the KMPDB's preliminary investigations show that the clinic had operated without a licence for some months before Ms Mulupi walked in for the second of a three-part surgery.
The KMPDB had granted Surgeoderm a licence on April 5 last year, yet Ms Mulupi's first procedure had been conducted two weeks earlier, on March 24, by Prof Khainga.
Investigators thus believe several illegal surgeries were performed at Surgeoderm since Ms Mulupi was not the only patient to have a breast augmentation procedure at the facility before April.
On June 5, when Ms Mulupi walked in for her appointment, Prof Khainga was running late and Dr Ojijo proceeded to perform a quarter of the procedure before his supervisor arrived.
He had already harvested fat from Ms Mulupi's abdomen through liposuction and was preparing to inject it into her breasts when Prof Khainga arrived.
A day after the surgery, on the morning of June 6, Mr Joseph Mulupi walked into Surgeoderm to take his wife home, but found her asleep.
He returned at noon and found his wife complaining of excruciating pain. She said she was feeling cold and he covered her with an extra blanket, then tried to feed her.
He was told he would take his wife home later that evening, but late in the afternoon he received a call from the clinic and was told that his wife was not eating.
He rushed to the clinic and, to his shock, found that his wife was unable to sit up or walk without assistance.
Her skin had started to turn pale but the clinic's staff told him that she would be fine if she ate.
He ordered for chicken from a nearby restaurant but, as he tried to feed her, a medic at the facility told him that her condition had worsened and she needed to be referred to another hospital urgently.
The family settled on Nairobi Hospital, according to Dr Ajujo's testimony. Prof Khainga however contradicted this while addressing the investigating committee.
He said he was attending to other patients at Nairobi Hospital when he received a call from Dr Ajujo, who explained the complications Ms Mulupi had developed.
Prof Khainga then told Dr Ajujo to transfer her to Nairobi Hospital. The KMPDB faults him for not disclosing to the other doctors that he had conducted the first augmentation surgery.
At Nairobi Hospital, records show that Ms Mulupi was seen by Dr Ajujo at the accident and emergency section at 11.45pm on June 6.
He admitted her at the high dependency unit but she died on June 7 after an hour-long attempt to resuscitate her failed.
The KMPDB's Preliminary Inquiry Committee presided over a hearing after Mr Mulupi filed a complaint against Dr Khainga and Surgeoderm Healthcare Limited.
The inquiry found out that at some point between 7.40pm and 11.15pm, Ms Mulupi's gut was nicked and waste flowed out, causing a blood infection commonly known as sepsis. This led to her death two days later.
However, an autopsy report by Dr Daniel Zuriel, who was hired by Prof Khainga, showed that Ms Mulupi had chocked on her own blood.
KMPDB did not believe the findings, and now says Dr Zuriel's report might have been intended to derail investigations into the botched surgery.
It had "glaring inconsistencies in comparison to two other reports" -- prepared by Chief Government Pathologist Johansen Oduor and Dr Joseph Ndung'u, who represented Nairobi Hospital -- the board says.
Both Dr Oduor and Dr Ndung'u reported that Ms Mulupi had died of sepsis.
As a result of these findings, KMPDB will now constitute a tribunal to do a full inquiry into Prof Khainga, Dr Ajujo, Dr Charana and Surgeoderm.
"By virtue of the fact that Prof Khainga agreed to perform the procedure, and actually performed the first part, there existed a duty of care owed to the patient," the KMPDB ruling reads in part.
"The committee further finds that the said duty was breached as Prof Khainga allowed an unqualified person to carry out a procedure on his patient."
Prof Khainga, Dr Charana and Dr Ajujo sued to stop KMPDB from probing them, claiming patient records showed that she had arrived at Nairobi Hospital while stable.
But Mr Mulupi disagreed. "After the ambulance arrived at Nairobi Hospital it had to be cleaned because my wife was leaking bodily liquids. She was then rushed to casualty and then taken to a resuscitation room," Mr Mulupi told the KMPDB committee.
Prof Khainga had objected to the preliminary inquiry, arguing that one of the members -- Dr Elly Nyaim Opot -- was on the opposing side of a case that he had filed in court as an official of the plastic surgeons' lobby.
Prof Khainga claimed he would not get a fair hearing owing to tension between him and Dr Opot.
He also claimed that Nairobi Hospital's Dr Reuben Okioma had injured Ms Mulupi's neck, leading to her death.
But Mr Mulupi said Dr Okioma was only trying to rectify the complications originating at Surgeoderm, and that Prof Khainga had attempted to settle the matter "amicably" by sending an emissary to strike a deal at the deceased's funeral.