UK NEWS

NEW MOTHER UNLAWFULLY KILLED IN EPIDURAL BLUNDER

Mayra Cabrera with her newborn son Zac

Tuesday February 5,2008

By Nicola McCafferty for express.co.uk

Comment Speech Bubble Have your say(4)

A NEW mother who died when an epidural drug was mistakenly fed into her arm at a hospital, was found to be unlawfully killed by an inquest jury today.

Filipino theatre nurse Mayra Cabrera, 30, died shortly after giving birth to son Zac, at Great Western Hospital in Swindon, Wiltshire, in May, 2004. Her newborn son survived.

Following the delivery, a potent epidural anaesthetic called Bupivacaine, was wrongly fed into a vein in her hand. When this drug is adminstered it should go into the space of a spinal cord.

The jury said gross negligence by Swindon & Marlborough NHS Trust, specifically sub-standard storage of drugs in the maternity unit, had led to the death.

Mrs Cabrera, who lived in Swindon and worked at the Great Western Hospital (GWH), died a short time later from a heart attack caused by Bupivacaine toxicity, her inquest at Trowbridge Town Hall heard.

Mrs Cabrera gave birth at 8.14am but by 9am, shortly after the error, she began to fit.

At 10.27am she was certified dead.

The inquest heard that her husband, Arnel Cabrera, was told immediately afterwards that she had died from an amniotic fluid embolism.

But he learned a year later, after instructing a lawyer, that she had in fact died because Bupivacaine had been administered incorrectly.

Midwife Marie To came on duty just after the birth and is alleged to have attached the Bupivacaine to Mrs Cabrera’s drip.

She denied having done so in evidence, insisting she thought it was either saline solution or Gelofusine, a blood volume expander to boost blood pressure.

During the failed resuscitation a 500ml Bupivacaine bag was found attached to the drip apparatus, the inquest heard.

Swindon & Marlborough NHS Trust admitted liability but, following a police inquiry, the Crown Prosecution Service decided not to charge anyone.

The month-long hearing was told there had been two other deaths at hospitals in the UK in the last decade caused by Bupivacaine being administered intravenously.

A few weeks after one, that of 74-year-old Philip Silsbury in 2001 at Royal Sussex County Hospital, a memo was sent round the NHS Trust advising that Bupivacaine be kept separately from intravenous drugs to reduce the chance of a mix-up. At the time the hospital was at its old Princess Margaret Hospital site in Swindon, prior to its 2002 move to GWH.

The inquest heard that storage of the drug at the GWH delivery suites was “chaotic”, not meeting the requirements.

It was not until after Mrs Cabrera’s death that this was amended.

Malcolm Fortune, for the NHS trust, argued that, chaotic drug storage or otherwise, the main blame lay with the person - Mrs To, he alleged - who had attached the bag to the drip without properly checking the contents label - “Bupivacaine: For epidural use only”.

FILIPINO MOTHER

05.02.08, 11:34pm

Well after watching the news tonight I could not contain myself as to the woman's dangerous waving around of her broken Brolly with at least 4 to 5 inches of bare spike sticking out of one of the wind damaged rods.

I was expecting her to poke a pedestrians eye out any second and be headlines for a second time.

Obviously cheap for the NHS but not the best or brightest bulb available on the market.

I hope the husband and child get indefinite leave to remain as they don't hate this country or want to change it or our way of life. The poor child needs compensation for her future and the terrible loss of her mother.

The NHS must pay for its shortcomings and the nurse needs a court case and investigation.

• Posted by: ubique • Report Comment

NEW MOTHER UNLAWFULLY KILLED

05.02.08, 8:43pm

According to the news today, the midwife involved showed no remorse at the inquest, nor did she acknowledge that she had administered the fatal drug. Well who did then? The pink elephant? Apparently the midwife was offered bereavement counselling - so that´s ok then. This hospital covered this appalling matter up from the start, no doubt hoping that as the husband was foreign, he would accept whatever rubbish they chose to tell him. Thankfully he, being made of sterner stuff, pursued this matter, and the truth came to light. All those involved in this cover up should be sacked, and the midwife should face a manslaughter charge at the very least.

• Posted by: KatieW • Report Comment

WHAT!!!!!

05.02.08, 6:48pm

Did the cleaning lady administer it?
Welcome to nu labour Britain,incompetence rules.
Surely,in a delivery ward this would be basic.

• Posted by: rozipoz • Report Comment

EPIDURAL BLUNDER!

05.02.08, 4:13pm

This is a complete and utter disgrace and had obviously been covered up from the day this happened. What a disgraceful indictment on our health service - isn't it enough we have to put up with the risk of catching the MRS drug in our hospitals without nurses giving fatal injections to their patients. So the nurse who injected this drug has been let off scot free - no surprise there then - people rarely get anywhere with the Medical authorities in cases of misjudgement that lead to death!

• Posted by: Wooram • Report Comment