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Mother's epidural death unlawful Mother's epidural death unlawful
(10 minutes later)
A theatre nurse who died after being mistakenly given an epidural in her arm was unlawfully killed, an inquest jury has ruled.A theatre nurse who died after being mistakenly given an epidural in her arm was unlawfully killed, an inquest jury has ruled.
Mayra Cabrera, 30, died shortly after giving birth to son Zac at the Great Western Hospital, Swindon, on 11 May 2004. The baby survived.Mayra Cabrera, 30, died shortly after giving birth to son Zac at the Great Western Hospital, Swindon, on 11 May 2004. The baby survived.
Midwife Marie To is alleged to have administered the drug Bupivacaine but denied this in evidence.Midwife Marie To is alleged to have administered the drug Bupivacaine but denied this in evidence.
Swindon & Marlborough NHS Trust had previously admitted liability.Swindon & Marlborough NHS Trust had previously admitted liability.
A spokeswoman again apologised after the inquest, adding: "This case should not have happened and I hope other hospitals will be able to learn from the bitter lessons we have learnt."A spokeswoman again apologised after the inquest, adding: "This case should not have happened and I hope other hospitals will be able to learn from the bitter lessons we have learnt."
The jury said gross negligence by the trust, specifically sub-standard storage of drugs in the maternity unit, had led to the death.The jury said gross negligence by the trust, specifically sub-standard storage of drugs in the maternity unit, had led to the death.
'Bitter and angry''Bitter and angry'
Coroner David Masters made a number of recommendations - which the trust said it would enact - including better labelling of drugs and enforced annual appraisals for midwives.Coroner David Masters made a number of recommendations - which the trust said it would enact - including better labelling of drugs and enforced annual appraisals for midwives.
Mrs Cabrera, who came to Swindon from the Philippines in 2002, died from a heart attack caused by Bupivacaine toxicity.Mrs Cabrera, who came to Swindon from the Philippines in 2002, died from a heart attack caused by Bupivacaine toxicity.
His wife is killed by a blunder, then the Crown Prosecution Service decide not to prosecute anyone, and now he faces deportation Solicitor Seamus EdneyHis wife is killed by a blunder, then the Crown Prosecution Service decide not to prosecute anyone, and now he faces deportation Solicitor Seamus Edney
Her 38-year-old husband Arnel now faces deportation to the Philippines.Her 38-year-old husband Arnel now faces deportation to the Philippines.
After the inquest Mr Cabrera, who was originally told his wife had died from an amniotic fluid embolism, said he was satisfied with the outcome of the inquest. After the inquest Mr Cabrera, who was originally told his wife had died from an amniotic fluid embolism, told a press conference: "Our life together was ripped apart by the action of a midwife who failed to check the fluid she gave to my wife.
He added: "Our life together was ripped apart by the action of a midwife who failed to check the fluid she gave to my wife.
"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.""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."
Mrs To, who retired last year, came on duty just after the birth and is alleged to have attached Bupivacaine to Mrs Cabrera's drip.Mrs To, who retired last year, came on duty just after the birth and is alleged to have attached Bupivacaine to Mrs Cabrera's drip.
She denied having done so, insisting she thought it was either saline solution or Gelofusine, a blood volume expander to boost blood pressure.She denied having done so, insisting she thought it was either saline solution or Gelofusine, a blood volume expander to boost blood pressure.
Counsel for Mrs To said the verdict was a British legal landmark - the first unlawful killing verdict found against an NHS corporation, as opposed to a named individual within one.
The trust said it had carried out an investigation which had apportioned no blame, and the findings as to exactly what had happened were inconclusive.The trust said it had carried out an investigation which had apportioned no blame, and the findings as to exactly what had happened were inconclusive.
Police investigationPolice investigation
Detective Inspector Ian Saunders, of Wiltshire Police, said he would now be referring the case to the Crown Prosecution Service.Detective Inspector Ian Saunders, of Wiltshire Police, said he would now be referring the case to the Crown Prosecution Service.
"Our thoughts are with Mayra's family at this sad time," he added."Our thoughts are with Mayra's family at this sad time," he added.
Mrs Cabrera's job as a nurse at the hospital where she died, and where her husband also worked, was the reason the couple had been granted leave to stay until 2009.Mrs Cabrera's job as a nurse at the hospital where she died, and where her husband also worked, was the reason the couple had been granted leave to stay until 2009.
Her husband's immigration status has changed since Mayra's death and his visa had been extended only until the end of February.Her husband's immigration status has changed since Mayra's death and his visa had been extended only until the end of February.
CORONER'S RECOMMENDATIONS EU "must address" labelling of epidural bagsColour and bar coding bags should be consideredAll midwives to have annual appraisalsMaternity unit at GWH to have own pharmacistTrust to carry out regular checks of drugsCORONER'S RECOMMENDATIONS EU "must address" labelling of epidural bagsColour and bar coding bags should be consideredAll midwives to have annual appraisalsMaternity unit at GWH to have own pharmacistTrust to carry out regular checks of drugs
Seamus Edney, Mr Cabrera's solicitor, added: "For all the setbacks he has had to put up with - his wife is killed by a blunder, then the Crown Prosecution Service decide not to prosecute anyone, and now he faces deportation - if we can get Arnel permanent leave to stay, then at least that will be one positive outcome."Seamus Edney, Mr Cabrera's solicitor, added: "For all the setbacks he has had to put up with - his wife is killed by a blunder, then the Crown Prosecution Service decide not to prosecute anyone, and now he faces deportation - if we can get Arnel permanent leave to stay, then at least that will be one positive outcome."
The coroner also backed the call for Mr Cabrera to stay in the UK.The coroner also backed the call for Mr Cabrera to stay in the UK.
A spokesman for the Home Office said: "An individual who does not meet the requirements under the immigration rules can in exceptional circumstances - for instance compassionate reasons - apply for discretionary leave to remain in the UK.A spokesman for the Home Office said: "An individual who does not meet the requirements under the immigration rules can in exceptional circumstances - for instance compassionate reasons - apply for discretionary leave to remain in the UK.
"When we receive an application such as this, we would obviously consider all circumstances surrounding the application.""When we receive an application such as this, we would obviously consider all circumstances surrounding the application."
The couple's son Zac has been looked after in the Philippines over the past few years as his father prepares to pursue a civil claim against the NHS trust.The couple's son Zac has been looked after in the Philippines over the past few years as his father prepares to pursue a civil claim against the NHS trust.