A new mother was unlawfully killed when an epidural drug was mistakenly fed into her arm via an intravenous drip, an inquest jury found today.
Filipino theatre nurse Mayra Cabrera, 30, died shortly after giving birth to son Zac, who survived, at Great Western Hospital (GWH) in Swindon, Wiltshire, on May 11, 2004.
Following the delivery, Bupivacaine, a potent epidural anaesthetic, was wrongly fed into a vein in her hand - if given at all it should have gone into the space of her spinal cord.
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 jury foreman, returning the verdict, said: "Mayra Cabrera was killed unlawfully - gross negligence/manslaughter - storage and administration."
Mrs Cabrera, who lived in Swindon and worked at the GWH, died a short time later from a heart attack caused by Bupivacaine toxicity, her inquest at Trowbridge Town Hall heard.
The jury of six women and three men took 17 and a half hours to reach its majority verdict.
Mrs Cabrera gave birth at 8.14am but by 9am, shortly after the error, she began to fit. At 10.27am she was certified dead.
Her husband, Arnel Cabrera, was told immediately afterwards that she had died from an amniotic fluid embolism, the inquest heard.
But he learned a year later, after instructing a lawyer, that she had in fact died because Bupivacaine had been administered wrongly.
Midwife Marie To came on duty just after the birth and is alleged to have attached the Bupivacaine to Mrs Cabrera's drip.
She denied having done so in evidence, insisting she thought it was either saline solution or Gelofusine, a blood volume expander to boost blood pressure.
During the failed resuscitation a 500ml Bupivacaine bag was found attached to the drip apparatus, the inquest heard.
Swindon & Marlborough NHS Trust admitted liability but, following a police inquiry, the Crown Prosecution Service decided not to charge anyone.
The month-long hearing was told there had been two other deaths at hospitals in the UK in the last decade caused by Bupivacaine being administered intravenously.
A few weeks after one, that of 74-year-old Philip Silsbury in 2001 at Royal Sussex County Hospital, a memo was sent round the NHS Trust advising that Bupivacaine be kept separately from intravenous drugs to reduce the chance of a mix-up. At the time the hospital was at its old Princess Margaret Hospital site in Swindon, prior to its 2002 move to GWH.
The inquest heard that storage of the drug at the GWH delivery suites was "chaotic", not meeting the requirements.
It was not until after Mrs Cabrera's death that this was amended.
Malcolm Fortune, for the NHS trust, argued that, chaotic drug storage or otherwise, the main blame lay with the person - Mrs To, he alleged - who had attached the bag to the drip without properly checking the contents label - "Bupivacaine: For epidural use only".