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New mother was "unlawfully killed"

An inquest jury has found that a new mother was unlawfully killed when an epidural drug was mistakenly fed into her arm via an intravenous drip.

Filipino theatre nurse Mayra Cabrera, 30, died shortly after giving birth to son Zac, who survived, at Swindon's Great Western Hospital (GWH) in May, 2004.

After the delivery, Bupivacaine, a potent epidural anaesthetic, was wrongly fed into a vein in her hand.

The jury said gross negligence by Swindon & Marlborough NHS Trust, specifically sub-standard storage of drugs in the maternity unit, had led to the death.

The inquest at Trowbridge Town Hall heard that Mrs Cabrera, who lived in the town and worked at the GWH, died a short time later from a heart attack caused by Bupivacaine toxicity.

The jury of six women and three men took 17 and a half hours to reach its majority verdict.

Mrs Cabrera's widower, Arnel Cabrera, said in statement: "Mayra was my love and my life. 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."

Swindon & Marlborough NHS Trust

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What do you think should happen to this theatre nurse? Should she be allowed to continue to practice?  Please supply your name and location. Your details will not be published if you so request. (Terms and conditions apply)

"We all make mistakes and have to live with the consequences of them. Thank goodness few end up in such tragic circumstances - they become very steep and painful learning curves - it is important to admit these mistakes and ensure, through training and change in practices that they are not repeated. There are so many factors that make mistakes inevitable - understaffing, poor skill mix etc - however I do believe this nurse should not continue to practice. My heart goes out to the family, but also to the nurse, who will probably never forgive herself. Sometimes the responsibility of the job of nursing is overwhelming but incredibly satisfying" - Name and address supplied

"We all need to be more careful in this time of pressure" - Name and address supplied

I wonder where her support team were during this tragic and stressful incident. I know we have to take be accountable for our best efforts, but we (I) don't know her side of the situation. Maybe she asked the person prescribing the drug "Is this Ok?" & he/she ASSUMED (that dreaded word!). She knew how/where/when/ to do it. She ought not to take all of the blame although this is of course unforgivable" - Name and address supplied

"NO, NO, NO, NO. A total disregard for basic safety is unforgivable" - Name and address supplied

"She made a huge mistake but for the grace of God it could have been any other nurse in a pressurised health service. I think this nurse will punish herself for life, she doesn't need us to judge her. She needs training, supervision and support to continue in her job" - Name and address supplied

"I think the nurse should undergo a period of active suppervison in order to establish her suitability to deliver independent care. I think she should not be assigned any complex duties such as administration of drugs until she is deemed competent. An investigation needs to be properly done as to why such a gross mistake was allowed to occur and standards set to ensure that this will not happened again, no matter whom the nurse is" - Name and address supplied

"What a terrible tragedy. The poor nurse who administered the drug is going to be hung out to dry, as nurses often are, regardless of what happened or any doctor's involvement. Apart from [Beverley] Allit, no nurse enters the profession with the intention of harming anyone and she will also be a life long casualty of this dreadful mistake. When I worked in the hospital there was a dreadful shortage of staff (and still is although they officially deny it) and it was all too easy to get swept away in the pressure of an emergency scenario. There was poor management of drug storage in many areas, not just maternity, and I often wondered when such a tragedy would occur.  The hospital had a huge influx of Band 5 nurses, particularly from abroad, who are not as accustomed to challenging the orders of the doctors or yelling for them to wait while they get drugs properly checked. That takes confidence from more senior and experienced nurses who became a casualty in the recent cull of Band 6 and 7 nurses (of which I am one) to save money. By allowing the nurse concerned to continue practising will be an insult to the family and the justice system; alternatively there was no malice intended and it was a mistake I don't suppose she will ever make again.  She was unlucky enough to get "caught" by a mistake that many nurses make every day without such tragic consequences, and it is wrong for any nurse to get on her high horse and demand draconian punishment for what, hand on heart, many do every day.  It would help matters if the nurse concerned did not continually deny any wrong doing in what is emerging as obvious liability. I would like to see the management of the trust and the government with their swingeing cuts take a proportion of the blame" - Name and address supplied

"Honestly I don't think she should be allowed to continue to practice. Mistake happens but when it costs the life of somebody, it's very serious" - Name and address supplied