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An NHS Trust has been fined after a mother who had just given birth died when she was given the wrong drug.
Great Western Hospitals NHS Trust was prosecuted by the Health and Safety Executive (HSE) after 30-year-old Mayra Cabrera died at the Marlborough Road hospital in Swindon on 11 May 2004.
Mrs Cabrera, who was also a nurse at the hospital, was given an epidural drug in her arm instead of a saline solution. She died an hour later following medical complications caused by the drug mix-up.
Investigations by the Health and Safety Executive (HSE) and Wiltshire Police showed that the two drugs were stored in the same racking system, despite having almost identical packaging.
Bristol Crown Court today fined Great Western Hospitals NHS Trust £75,000 after they admitted breaching Section 3 (1) of the Health and Safety at Work etc Act 1974 by putting the safety of patients, including Mrs Cabrera at risk due to the unacceptable storage of drugs and the administration of drugs. The Trust was also ordered to pay costs of £25,000.
Mayra Cabrera was a nurse at Great Western Hospital. She had just given birth to her first child, a boy, when she was wrongly given a rarely-used local anaesthetic, bupivacaine. She had been prescribed a saline solution to help raise her blood pressure, but instead the bupivacaine was selected due to a mix-up.
The consequent Police and HSE investigations showed that there was no proper management system for the storage of the drugs, and warnings from earlier incidents had not been properly actioned.
Speaking after the hearing, HSE Inspector, Liam Osborne, said:
"This was an absolutely heartbreaking case to investigate. Mayra Cabrera needlessly died as a result of comprehensive management failings at board, pharmacy and ward level.
"Had the hospital done something as simple as keeping these completely different but almost identical-looking drugs in separate cupboards, then Mrs Cabrera would not have died.
"It is really important that risks are properly assessed and safe systems put in place that minimise the chance of human error.
"The organisational failure to assess the risks and provide a safe system for the storage of these products placed any patient in the Maternity Unit at risk, from when the Great Western Hospital opened in December 2002, until the drugs were removed after Mrs Cabrera died in 2004.
"The trust failed in its duty of care to Mrs Cabrera, and the fact that she used to work for the hospital that ultimately ended her life makes this all the more tragic."
Mrs Cabrera's widower, Arnel Cabrera, said:
"It has now been six years since my wife, Mayra died and two years since the Inquest into her death was concluded and I would like to thank the HSE for bringing this prosecution and I am pleased with its outcome.
"It reinforces the importance of the health and safety of patients attending hospital and in particular the safe storage of dangerous drugs. Now this case has been concluded I am hoping that my young son and I can have some closure and put this terrible tragedy behind us."
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