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Trust admits guilt after nurse's drug error kills patient


A health trust has admitted breaching health and safety rules at Swindon Crown Court after a new mother, and nurse, died due to a drug error at the hospital where she worked.

The Great Western Hospitals NHS Foundation Trust pleaded guilty to breaches which led to the death of Mayra Cabrera.

The 30-year-old theatre nurse arrived at Great Western Hospital in Swindon where she worked, to give birth to her son Zac on 11 May 2004. But during her treatment a nurse incorrectly linked the epidural anaesthetic Bupivacaine to an intravenous drip attached to her arm.

The drip was intended to raise Mrs Cabrera’s blood pressure, but instead she died within minutes from a heart attack caused by Bupivacaine toxicity.

During the hearing the trust pleaded guilty to an offence under section 3 (1) of the Health and Safety at Work Act. The charge related to “risks arising from the storage of drugs and drugs errors”.

The case was adjourned for sentence at Swindon Crown Court at a date to be fixed.

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

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


Readers' comments (9)

  • it's a total chaos! yet they wanted to show to the whole world that they are the best!
    old habits never die.....

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  • My heart and sympathy goes to Late Mrs Crbrera and her family for this unfortunate incidence which is preventable in the first instance however, I strongly condemn the language used by the previous commentator who has chosen to remain anonymous. I have been in active practice for twenty six years which spread across Africa, Gulf Countries and Europe. NHS and its over-stretched health care workers towered well above any other healthcare system which remains incomparable globally. An isolated error, duly reported, investigated with guilt admitted is far more better than errors covered up without being reported. Lessons learnt from this incident will eventually strengthen the NHS services and continue to remain the best healthcare provider in the world to keep their detractors permanently silent.

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  • Was the Nurse working on her own or was she supervised because if she was new to that kind of work and worked unsupervised then the Nurse in charge should be made accountable for the mistake made

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  • Tragic. So sad for everyone involved. Fear of making a drug error keeps me awake at night.

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  • I know exactly what you mean Anna, knowing the potential consequences if we slip up is absolutely terrifying for me as well. We are only human at the end of the day, and all the best practice in the world can never account for human error. One mistake is all it takes and that is scary as hell.

    But I do have to comment on Gaphar's statement that a mistake is best reported, you are right in theory, but the problem is in the UK there is such a culture of blame, bullying and witchhunting that Nurses are reluctant to come forward and admit a mistake.

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  • I have always been an advocate of 2 nurses dispensing medications, whatever it is! It limits the possibility of drug errors. It used to be carried out in one area I worked and it worked damn well.

    My condelences go to Mrs Cabrera’s family and friends for their loss.

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  • Unfortunately these kind of tragedies will continue to happen whilst the NHS understaffs and overworks its staff. It is little wonder they don't happen more often as management adopt a " fly by the seat of their pants " attitude to nursing staff and patient care. I resigned my position with the NHS after years of banging my head on a brick wall. I was constantly reporting wards that were understaffed with poor skill mix to managers who were only interested in numbers and targets, filled with fear of " breaching " . I sent my letter of resignation to my immediate manager, Director of Nursing, Chief Exec. and both consultants. I knew my decision was right when no-one except the consultants responded. The consultants both spoke to me individually and told me they agreed with my points that at times the ward was unsafe due to inadequate staffing. One told me that he had expressed this in a recent meeting and had been told to " sit down and stop rocking the boat ". If a consultant has no chance of changing management attitudes then what chance do nurses have.This case is a tragedy for all concerned, for the family of the dead nurse and for the poor nurse who finds herself in this position, and I am sure the management will distance themselves as much as possible from any blame.

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  • Such tragedy that an error like this has occured, my heart felt condolences go to the family and the son who sadly will never know his mother. Unfortunately we are all human and errors do occur no matter how major or minor. However, i do believe are employers are as much to blame with understaffing, poor skill mixes, We all live in fear of the day that something like this might happen to ourselves. My fears at present are with early morning drug rounds we are expected to do after working night shift how unsafe is this, disaster waiting to happen.

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  • I have followed this very sad case and use it in my teaching for practitioners to reflect upon.
    I thought that the nurse involved was a "bank" midwife. My experience in midwifery is that the anaesthetist takes responsibility for epidural analgesia and as such should have had some accountability for the events.
    If the nurse (?midwife) did connect this as an IV fluid there must have been a catalogue of events for which several others had responsibility (drug ordering/storage/policy/training/equipment procurement etc.). Whilst accepting I may not be fully aware of the events, I feel slightly uneasy on the apportioning of blame in this case.
    When I open debate on this it does lead to many areas to be explored including accountability issues

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