A hospital trust has been fined £100,000 after a new mother died when an epidural anaesthetic was mistakenly administered intravenously instead of a saline solution. Mayra Cabrera, 30, a theatre nurse at the Great Western Hospital in Swindon, suffered a fatal heart attack within an hour of giving birth to a healthy son, Zachary, in 2012.
Bristol Crown Court heard that both substances were stored in similar packaging, contributing to the error. The Health and Safety Executive (HSE) said the death could have been prevented if the drugs had been kept in separate cupboards. The trust pleaded guilty to a workplace health and safety offence and was ordered to pay £75,000 in fines and £25,000 in costs.
Sentencing, Mr Justice Clarke cited 'systematic and individual fault', noting that the midwife involved 'could not have read the label carefully or possibly at all'. He added that avoidance of any one of a number of errors would 'probably have averted' the tragedy, stating: 'This tragedy happened despite the warning signs. No penalty I impose can restore a life lost.'
An inquest previously ruled that Mrs Cabrera was unlawfully killed, describing drug storage at the hospital as 'chaotic'. Her widower, Arnel Cabrera, who has since returned to the Philippines with their son, expressed relief at the conclusion of the case. He said: 'Now this case has concluded, I am hoping my young son and I can have some closure and put this terrible tragedy behind us.'
Lynn Hill-Tout, chief executive of the Great Western Hospitals NHS Foundation Trust, apologised, stating: 'As a result of what happened a husband does not have a wife and a son does not have a mother and we are truly saddened by that fact, as it is something that should never have happened.'
