Trust facing sentence after nurse error

17 May, 2010

A trust is due be sentenced for breaching health and safety rules after a new mother died after a nurse wrongly administered IV anaesthetic instead of saline.

Mayra Cabrera, 30, died shortly after giving birth to son Zac, who survived, at Great Western Hospital in Swindon, Wiltshire, on May 11 2004.

A nurse wrongly attached the epidural anaesthetic Bupivacaine to an intravenous drip attached to her arm instead of saline solution which she needed to help bring her blood pressure back up.

She died within minutes from a heart attack caused by Bupivacaine toxicity at the hospital where she had worked as a theatre nurse.

The Great Western Hospitals NHS Foundation Trust previously pleaded guilty to an offence under section 3 (1) of the Health and Safety at Work Act during a hearing at Swindon Magistrates’ Court.

The trust will be sentenced today at Bristol Crown Court.

The charge relates to “risks arising from the storage of drugs and drugs errors”.

An inquest at Trowbridge, Wiltshire, in February 2008 ruled that Mrs Cabrera was unlawfully killed, citing negligent storage of Bupivacaine as a reason for her death.

The inquest heard drug storage in the delivery suites was “chaotic”.

Mrs Cabrera gave birth to son Zac at 8.14am on May 11 2004, the inquest heard.

Following the error, she began to fit. At 10.27am she was certified dead.

Readers' comments (15)

Anonymous | 18-May-2010 9:11 am
I do not understand why the nurses responsible for administering the drug are not being held to account. Where I work, two nurses have to check the IV drugs to be given and go to the patient together and check the patient details against the prescription chart. It would seem from the limited info available that there is at least some responsibility on the part of the nurses in this matter. It would seem obvious to me that when dealing with such potent drugs, strict adherence to policy would be a paramount concern to responsible nurses, and eliminate such tragic events.
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Anonymous | 18-May-2010 9:41 am
You have to remember that unless an act is carried out with malicious intent (as with Beverley Allit) then the nurses made a mistake an error which unfortunately was with catastrophic consequences but I defy anyone to believe that they would never make any mistakes albeit with terrible consequences. With many of these instances it is the processes that are at fault not the person.
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Anonymous | 18-May-2010 10:26 am
The process of drug storage is at fault at this hospital and many other areas. The drugs especially the IV drugs need two qualified nurses to check before administering. The other reason might be shortage of staff on duty and hospitals need to look at this problem.
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Anonymous | 18-May-2010 12:29 pm
if it gets into a court room with formal charges and an admission of guilt by the trust you can bet the route cause was errors in policy and proceedure which is the resposibility of the trust.

the CEO and Directors deserve all they get!
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Anonymous | 18-May-2010 6:57 pm
while, it is an error not committed with malice, the family has still lost a very young mother with a newborn baby. whether it is the Trust or the nurse that is at fault, it is a huge loss for the family and unfortunately,no amount of speculation or compensation is ever going to change the truth!
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Anonymous | 19-May-2010 3:22 am
Right route, right drug, right time, right patient and right dose. These are the 5 rights in medication administration. Yes, mistakes happen but most of the time they can be prevented when one takes the time to check and double check. A bag of saline solution is obviously not the same as a bag of bupivacaine epidural solution. The nurse did not take the time to check and it cost a young mother her life. We all should learn from this terrible mistake.
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Anonymous | 19-May-2010 8:29 am
This is a terrible loss for the family of the new mother and for the newborn baby. Trusts should definately look at their policies and yes nurses do make mistakes, myself and my collegues included. However, having said that I can not understand how such a large mistake can be made, when you administer IV meds you know whether you're meant to be administering saline, antibiotics or anaesthetic, it's written in black and white. There is a huge difference between these. Yes, staff shortages does play a part in this and no doubt the nuse in question was stressed to the eyeballs. Again however, it does not take long to double check the drug and dose yourself before getting another nurse to check it with you and then triple checking it with the drug kardex and the patient before administration. I have done this countless times when there has only been another nurse and myself on a ward with thirty patients. Always check, even if it means drugs being handed out late. It's better than loss of life and registration on the line. What a sad story for the family and the nurse, she'll probably never get over it. I really feel for her, another stressed out nurse.
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Anonymous | 19-May-2010 11:47 am
I agree with the above comments, I can't believe this has happened. As nurses we have it drummed into us about medication administration and have strict guidelines to follow to prevent mistakes like this from happening. I am surprised that the nurses involved aren’t being made accountable though this may be occurring on a local level. We do need to address why this has occurred (staff education, staff shortages as well as medication storage etc) so it can’t happen again.
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judith willis | 19-May-2010 2:34 pm
This was a most tragic of cases and should NEVER have happened.
As previously stated, FIVE components are needed for safe and accurate administration of drugs.
When these drugs are intra-venous or intra-thecal, they should ALWAYS be checked by two persons.
This midwife should be held accountable.
There is a lesson here for all of us, however, and that is, never be coerced to cut corners or drop standards.
We are accountable for our actions and should never lose sight of that fact.
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Anonymous | 19-May-2010 10:39 pm
This is a most tragic and unfortunate event, and while all the arguements go back and forth there is a bereaved family asking how could this have happened. The article here does not state if this incident took place on the ward or not, but if it did it begs the question why is the practice of sending patients back to a busy ward with epidural infusions in situ or on infusion pumps of any kind allowed. It has been discontinued in many places because of the very real risk of incidents like this happening.
It is right that the trust in question is now held accountable - citing shortage of staff as a factor is not good enough, hospitals everywhere are experiencing staff shortages therefore policies must be seriously reviewed, adapted and implemented in response to this.
One feels for the nurse involved, for her as for the bereaved family the arguements will change nothing, they are left with trying to find a way of coming to terms with this tragic outcome.
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Anonymous | 21-May-2010 8:02 pm
In the trust where I work bupivacaine is kept locked in the CD cupboard.
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Anonymous | 24-May-2010 2:17 pm
systems error!...understaffed...overworked...stressed out.....rushed off her feet and at breaking point.

Any one of us could have made a similar mistake put in the same circumstances....there but for the grace of God.
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Anonymous | 24-May-2010 9:36 pm
the trust need to review its policies in storage of medications and working towards preventing any further untoward incident. its sad that a life was lost due to negligence but other factors need to be considered as well - lack of staff, competence of the nurse administering the drugs. display and storage of medications in that settings. this has to be looked at. mistakes happened but i think in thiS situation, drugs should have been checked by two qualified nurses on duty.
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Anonymous | 30-May-2010 10:32 pm

Hi there,

It is very embarrasing for the NHS staff including doctors and nurses for their neglience. It is very common in many trusts of the UK to make errors because of poor knowledge which may have occured during that time. And I don't think anyone can convience of what happened to that family which lost a young mum. And above all she was working in that hospital as a theatre nurse. How comes someone didn't treat her like a staff of the same hospital and ended up killing her in a big neglience? Nurses should know what they are doing all the times no matter what comes. They must read and understand properly and if there is any doubt on anything then ask the doctor immediately, they should not fear doctors if they are not sure of anything and stop pretending and end up killing people like that.
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Anonymous | 27-Jul-2010 12:46 pm
There is too much pressure being put upon staff recently, as we all know with cut-backs, staff shortage, lack of adequate skill-mix according to the appropriate speciality. For example, the trust where I work provides bank/agency trained nurses to fill in the shortfall of permanent staff due to various reasons. Although the accountability depends on the individual, the workload is increased for the other staff nurse as its a speciality unit and the temporary staff are unable to perform these duties. Increaseasinly band 3 HCA's sometimes take on patients apart from their medications. How can this be justified, somthing has to give and unfortuanately its the near misses that we have experienced. Countless risks forms filled etc. Staff have inadequate time to put a risk in each time and by doing so enabling them to be more stressed triggering a catch 22.There is no end to the stress, enormous pressure, unstable performance of the trust to act accordingly to protect all staff at all times not to compromise patient care. This said mistakes, big or serious are going to be made without a doubt and unfortunately patients are and will be put at serious risk.
To conclude this by saying training apart from BLS have all taken a back seat due to the same issues. Hence staff are unable to update on other training which are relevant to patient safety in learning about new equipment, dressings, etc etc.
So the catch 22 problem all over again.
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