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Wednesday, 6 February 2008

A midwife and senior medical staff could face prosecution after an inquest found that a new mother who died was unlawfully killed.

Hospital could be charged over fatal epidural

Extracts from the Telegraph:

"A midwife and senior medical staff could face prosecution after an inquest found that a new mother who died after she was given an epidural in her arm instead of her back was unlawfully killed.

Mayra Cabrera, 30, a nurse, suffered a heart attack caused by the anaesthetic within three hours of giving birth to her son, Zac, at the hospital where she worked in May, 2004.

An inquest heard how the tragedy happened after Sister Marie To, a midwife at the Great Western Hospital in Swindon, Wilts, allegedly attached the drip bag containing the epidural to a line going into Mrs Cabrera's arm, rather than one going into her back.

On Tuesday a jury said gross negligence by Swindon and Marlborough NHS Trust, specifically sub-standard storage of drugs in the maternity unit, led to Mrs Cabrera's death.

The verdict said she was "killed unlawfully, gross negligent manslaughter"."

"Gross negligence manslaughter applies equally to both the corporate body and individuals if there is evidence that a breach of duty of care is so great as to be characterised as gross negligence.

Speaking after the hearing, Mrs Cabrera's husband, Arnel, 38, who worked as a technician at the hospital, said: "Mayra was my love and my life. We were overjoyed when Zac was born. However our life 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 the 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.""

"David Masters, the Wiltshire coroner, said he would be writing to the Health Secretary to recommend a series of changes, in particular the introduction of epidural use-only equipment.

He would also be writing to the trust to recommend improvements in storage systems, training and administration in the maternity unit.

In 1994 and 2001 there were similar, non-fatal, bupivacaine errors at the old Princess Margaret Hospital in Swindon.

The hospital trust subsequently introduced a policy to store the drugs in locked cupboards but the inquest heard that when the hospital moved to its new site in Swindon in 2002, the policy was ignored."

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