The Health and Safety Executive (HSE) has successfully prosecuted Great Western Hospitals NHS Trust, after a 30-year-old patient – who was also a nurse at the trust – died after she was given an epidural drug in her arm instead of a saline solution drip.

In May 2004, Mayra Cabrera gave birth at Marlborough Road Hospital in Swindon, Wiltshire – she was a nurse at Great Western Hospital.

She had just given birth to her first child – a boy – when she was wrongly given a rarely-used local anaesthetic, bupivacaine.

Doctors had prescribed a saline solution to help raise her blood pressure, but bupivacaine was selected by mistake. An investigation by the HSE and Wiltshire Police discovered that the two drugs were stored in the same rack, despite having almost identical packaging.

The subsequent police and HSE investigation also showed that there was no proper management system for the storage of the drugs – and warnings from earlier incidents had not been actioned properly.

Mrs Cabrera died an hour after having been given the drug in her arm.

On Tuesday (17/05/10) at Bristol Crown Court, Great Western Hospitals NHS Trust admitted breaching Section 3 (1) of the Health and Safety at Work etc Act 1974 by putting the safety of patients – including Mrs Cabrera – at risk, due to the unacceptable storage of drugs and the administration of drugs. The trust was fined £75,000 and ordered to pay £25,000 costs.

Speaking after the hearing, HSE inspector Liam Osborne said that Mrs Cabrera had died needlessly ‘as a result of comprehensive management failings at board, pharmacy and ward level’. Mr Osborne added that the case had been ‘heartbreaking’ to investigate.

‘Had the hospital done something as simple as keeping these completely different but almost identical-looking drugs in separate cupboards, then Mrs Cabrera would not have died,’ he said.

‘It is really important that risks are properly assessed and safe systems put in place that minimise the chance of human error,’ added Mr Osborne.

Mr Osborne also said that the ‘organisational failure’ to assess the risks and provide a safe system for the storage of the drugs ‘placed any patient in the maternity unit at risk’ from the time the Great Western Hospital opened in December 2002 until the drugs were removed after Mrs Cabrera died in 2004.

‘The trust failed in its duty of care to Mrs Cabrera,’ said Mr Osborne. ‘And the fact that she used to work for the hospital that ultimately ended her life makes this all the more tragic,’ he added.

Following the hearing, Mrs Cabrera’s widower, Arnel Cabrera, said:

‘It has now been six years since my wife, Mayra, died and two years since the inquest into her death was concluded – and I would like to thank the HSE for bringing this prosecution and I am pleased with its outcome.

‘It reinforces the importance of the health and safety of patients attending hospital – and in particular, the safe storage of dangerous drugs.

‘Now this case has been concluded, I am hoping that my young son and I can have some closure and put this terrible tragedy behind us.’

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