Midwife may face charges over drug death of new mother injected with epidural in her arm

Mayra Cabrera suffered a heart attack after mistakenly being given an epidural drug via an intravenous drip.

The 30-year-old Filipino had just held her son, Zac, for the first time.

The jury was told that the powerful epidural used, Bupivacaine, should have been locked safely away from intravenous drugs.

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But "chaotic" storage arrangements at the Great Western Hospital in Swindon - where Mrs Cabrera herself worked as a theatre nurse - meant this did not happen. Epidural drugs should be administered only into the spine.

Marie To, the midwife sister accused of attaching the drip, had told the month-long hearing she was not to blame for the fatal blunder.

Mrs Cabrera's husband, Arnel, insisted yesterday, however, that she should be prosecuted.

"Mayra was my love and my life," he said. "On 11 May 2004 we were overjoyed when our son, Zac, was born. However, our life together was ripped apart by the action of a midwife who failed to check the fluid she gave to my wife.

"She had six opportunities to check this fluid. Had she done so, Mayra would have been alive today.

"The midwife's failure to accept responsibility or show any remorse for her actions has made me very bitter and angry.

"I cannot forgive her and now hope that the police and Crown Prosecution Service will prosecute her for manslaughter."

Mrs To, who came on duty just after the birth, claimed she had hooked up to the drip either a saline solution or a drug to boost blood pressure.

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But medics who tried to resuscitate Mrs Cabrera found a 500ml Bupivacaine bag attached to the apparatus.

Mrs To, who has retired after 20 years as a nurse, said she did not put the bag there.

She admitted, however, that she had not gone through all the required checks, including asking a doctor to verify the drip bag.

Malcolm Fortune, counsel for Swindon and Marlborough NHS Trust, which has admitted liability for the death, argued that the main blame lay with Mrs To.

He told the hearing in Trowbridge, Wiltshire, that she attached the bag to the drip without properly checking the label, "Bupivacaine: For epidural use only".

A police inquiry was carried out into the death but the Crown Prosecution Service decided against bringing charges.

Yesterday Wiltshire Police, which led the original investigation, said the file had been passed back to the CPS for reexamination.

A spokesman said: "The CPS will carefully review what has >been said in these proceedings to see if any new evidence has come to light. This will include full transcripts of the entire hearing."

The jury returned a verdict of unlawful killing through gross negligence, blaming the substandard storage of drugs at the hospital.

It is believed to be the first time a Health Service trust has been found responsible for unlawful killing, rather than a named individual, and paves the way for prosecution of hospital chiefs.

The inquest was told that epidural drugs had been administered intravenously at the Great Western Hospital three times without fatal results. Over the past decade, similar mistakes have caused the deaths of two elderly men at other hospitals.

Wiltshire coroner David Masters is to write to the Health Department to recommend fundamental changes to the administration and storage of medicines.

Lyn Hill-Tout, chief executive of the Swindon health trust, apologised yesterday to Mr Cabrera and his son. "Mayra's death was avoidable," she said.

"This verdict reflects that. We have been criticised for a number of failures which we accept, deeply regret and from which we have learned important lessons."

She said health staff now ensured Bupivacaine was stored in locked cupboards.

Mr Cabrera, 38, faces deportation from Britain because his immigration status changed when his wife died.

He was granted permission to stay and work here in 2003 after joining her in Swindon following her recruitment by the NHS a year earlier.

His son, now four, is being cared for by relatives in the Philippines but he said it was his wife's wish to bring him up in Britain.

Mr Cabrera, who has been travelling between the two countries during the investigations into his wife's death, is pursuing a civil claim against the health trust.