A hospital trust has been ordered to pay £100,000 after a mother who had just given birth died due to a mix-up between “identical looking” drugs.
Mayra Cabrera, 30, died hours after giving birth to son Zac, who survived, at Great Western Hospital in Swindon, Wiltshire, on 11 May 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.
Ms Cabrera - who was a nurse at the same hospital - died within minutes from a heart attack caused by the toxic effects of bupivacaine.
The two drugs had “almost identical packaging” and her life could have been saved if the bags were kept in separate cupboards, the Health and Safety Executive said today.
Great Western Hospitals Foundation Trust was ordered to pay £75,000 in fines and £25,000 in costs by a judge at Bristol Crown Court. The trust had pleaded guilty to an offence under the Health and Safety at Work Act.
Passing sentence today, Mr Justice Clarke said: “No one could be unmoved by this tragedy. No one who knew what lay behind it could be untroubled at the systematic and individual fault which this inquiry revealed.”
The nurse, who was suspended and is now retired, “could not have read the label carefully or possibly at all”, he added, also citing the inadequate drugs storage as a factor in Ms Cabrera’s 2004 death.
An inquest at Trowbridge, Wiltshire, two years ago ruled that Ms Cabrera was unlawfully killed, also citing the “chaotic” drug storage.
Nursing Times practice content
Registering for free on nursingtimes.net gives you access to thousands of peer-reviewed articles that will help you improve your nursing practice.
After you register, you’ll have access to our practice archive, including all-time favourites such as: