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.
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. Mrs 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.
The Great Western Hospitals NHS 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, 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 midwife, 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 Mrs Cabrera's 2004 death. An inquest at Trowbridge, Wiltshire, two years ago ruled that Mrs Cabrera was unlawfully killed, also citing the "chaotic" drug storage.
Mrs Cabrera gave birth to son Zac at 8.14am on May 11 2004. She began to suffer a fit and at 10.27am she was certified dead.
Source: The Metro