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£100,000 fine over hospital death

  • 8 Comments

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.

 

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  • 8 Comments

Readers' comments (8)

  • rovergirl6@hotmail.com

    I suggest that one nurse only on each shift should be responsible for medication. And she /should have specialised in theory and application of medicines ie a degree in medication and its uses side effects efficacy and so on .

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  • Hi,

    NHS Staff please don't play with someone's life like that. NHS has not paid enough money for the chaotic it made for that family. That is the newborn baby and whoever is going to look after that child. All the staff of NHS should be highly trained and docotors should assist nurses to make sure the medication is given the right way. They wshould work interprofessionallyfor example if there is any doubt to communicate to each other so that best care is given to patients. And above all that hospital must be closed down as it is in a big mess of killing a young mum intentionally and suffering the newborn baby. Suppose all of the staff who were involved were not brought up by their mums, would they have reached where they are now? Many midwives are putting all the women who go to have child at risk. There is alot needed for midwives to be trained more and have good manners than rubbish. Midwives have poor education in the UK therefore government needs to come in and help. Otherwise this will continue costing NHS alot and alot more all the times.

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  • Nice to see the nurses of today are well educated, is that comment above serious?

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  • Midwives are highly educated and the comments made above are very offensive and unprofessional.

    My sympathies go out to the family and their loss of a mother to a child.

    Simple solutions to these errors can be enforced such as two people checking the bags of fluids before they go up. This is what we do in our trust. It’s for peace of mind and two pairs of ey::es are always better than one. Changes are being made as we all know.

    I agree fatalities like this should not happen but I am sure that the trust in question have stepped up on their policies and enforcing vigilance in administering drugs

    The comments made at 9:52 on the 19th are obviously made by someone who either does not work in the profession or are not aware of the pressures ward based areas are under to perform. This incident should not have happened but lets try and learn something from this so no one else loses their life in the same tragic and unnecessary way

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  • Illegible doctors hand writing and interruption is problematic.


    Prescription chart should be written in capital letter to reduce drug error.

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  • My sympathy go out to the little boy who has to grow up without his mother and her family. This shouldn't happen and is totally wrong, however I find the comment above associating this with poor midwifery education in the UK highly offensive. I wonder if the person who wrote this is aware of what the midwifery education and training in the UK involves.

    I think this case highlighted how easy human being can make mistakes, a fatal one in this case. It is each individual midwife's as well as the trust's responsibilities to ensure drug administration and safety policy are adhered to at all times. It is also important to ensure all midwives have regular updates and further training in their clinical practices.

    We have heard about the shortage of midwives often through the media and this have already put many existing midwives under enormous work pressure and stress. I am concern with the further cuts in the NHS in the forthcoming years (very often maternity is considered lower in the priority of service list), how the mothers' and babies' safety can be ensured.



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  • Always have all intravenous and epidural medications double checked by a second RN or RM, then scenario's likethis can be prevented.

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  • First my deepest sympathy on learning of this accident goes to the family of the patient. I believe such a tragedy must affect most of us in the nursing profession and make us reflect more deeply on our own practice and what safeguards can be put in place to make drug administration safe for all patients.

    Anonymous | 19-May-2010 9:52 pm

    This comment is obviously an emotional reaction which reflects justified concern and fear but unfortunately it is flawed in its argumentation. It appears to be written by somebody who does not have a clear understanding of the workings of the NHS.

    "And above all that hospital must be closed down as it is in a big mess of killing a young mum intentionally and suffering the newborn baby."

    "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."

    There is no suggestion in the article that it was a case of intentionally killing the patient, although this is not ruled out, but it suggests negligence and although not mentioned other causes could be attributed to problems of adequate training and supervision, job stress and staffing shortage. This information is not given in the article.

    "Suppose all of the staff who were involved were not brought up by their mums, would they have reached where they are now?"

    this is derogatory as it suggests that those midwives, or other healthcare professionals for that matter, who were not brought up by their mothers would not have reached professional level. I am sure there are some midwives and other professionals who did not have the privilege of being brought up by their own mother but are nevertheless excellent at their jobs and have successful careers.

    "There is alot needed for midwives to be trained more and have good manners than rubbish. Midwives have poor education in the UK therefore government needs to come in and help. Otherwise this will continue costing NHS alot and alot more all the times."

    This statement is entirely flawed and makes false assumptions and accusations. Midwives are highly educated in the UK. Most have a highly responsible job which they do to the best of their ability, within the financial and other resource constraints imposed by their employers, with the needs of their patients central to their care. They also play an educative role.

    The attack on their manners is a sweeping generalization, which may apply to a very small percentage of medical staff and midwives. These alleged 'bad manners' may also be a transitory reaction to to difficult and stressful day at work, which happens to everybody from time to time, and their very high level of responsibility, or even on provocation from the patient, colleagues or their managers, and it is not always easy to meet all the demands of the job and especially those of lower priority when they have to constantly cope with emergencies and unforeseen circumstances. This takes its toll and increases fatigue and job performance at times which can be testing even to the most experienced and the most resilient personalities.

    Manners have little to do with the tragic accident in this article although there is a relation between attitude and manners.

    There are good suggestions by nurses in the comments above to help prevent accidents of this type, such as that by Sandra Joyce Odell -Powell | 19-May-2010 3:46 pm. I would add that the nurse responsible might need to be relieved of some of the other duties so that there is time to concentrate on the administration of drugs as it is lack of attention, stress and fatigue caused by the high pressure of the job which can often be attributed to human error and drug errors.

    Previously we were always two to check iv fluids and some other medication but this has also been shown not to be totally foolproof because under stress one nurse can be distracted and can agree without really checking, whilst relying on the other to check the drug. If both do this, the consequences can be disastrous.

    I must say that there are times when work is so busy and stressful it would be good to be relieved of the duty of administering drugs which require considerable concentration which is difficult with constant interruptions and it might work well to have one or even two nurses, experienced in drug delivery, per shift in charge, depending on the quantity and nature of drugs to be administered.

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