Inquest hears of three drug mix-ups (From The Wiltshire Gazette and Herald)

Inquest hears of three drug mix-ups

4:08pm Thursday 17th January 2008 in Swindon

There were up to three potentially fatal drug mix-ups by an NHS trust's midwives before a fourth led to a woman's death, an inquest jury heard today.

Christina Rattigan, head of midwifery at Great Western Hospital (GWH), agreed that a number of Swindon & Marlborough NHS Trust policy breaches had occurred in the lead-up to 30-year-old Mayra Cabrera's death shortly after giving birth to son Zac.

The hearing at Trowbridge in Wiltshire has heard how Bupivacaine, an epidural anaesthetic, was mistakenly given to Mrs Cabrera via intravenous drip. Mrs Cabrera, who came to Swindon from the Philippines in 2002 to work as a theatre nurse at GWH, died of Bupivacaine toxicity on May 11, 2004.

Today in evidence Mrs Rattigan said there had possibly been a similar mix-up with Bupivacaine, in 1994, although her recollection was sketchy.

Gerwyn Samuel, for Mrs Cabrera's husband Arnel, told the court that in 2001 there were two other non-fatal incidents - one involving Bupivacaine - where epidural drugs were wrongly set up for intravenous infusion.

These three incidents took place at the former Princess Margaret Hospital in Swindon, which was replaced by GWH in 2002.

Also in 2001, a memo was sent to hospitals around the country following the death at Royal Sussex County Hospital of Philip Silsbury, 74, of Littlehampton, West Sussex, after he too was mistakenly given Bupivacaine intravenously.

A note distributed around GWH by its chief pharmacist asked staff to ensure Bupivacaine was clearly marked and stored separately from intravenous drugs. But the inquest heard this failed to happen until after Mrs Cabrera's death.

Mr Samuel put it to Mrs Rattigan that, bearing in mind past incidents, the error in Mrs Cabrera's case was "more serious" still.

"Yes," she replied.

It is alleged that Marie To, a midwife at GWH, mistakenly put up the Bupivacaine drip into Mrs Cabrera's hand.

Mr Samuel asked Mrs Rattigan: "Is there any way you can defend a midwife who fails to read a label on a draw, read writing on a bag (of fluid) to make sure she had got the right drug, and fails to go to a doctor to get it cleared?"

Mrs Rattigan replied: "The checks are in place to ensure that the woman gets the right drugs and any failure in carrying that out can put the woman at risk."

The barrister, describing it as "an atrocious failure", said: "It is an abysmal state of play, is it not, to find one of you midwives failing in so many ways?"

"Yes," came the reply.

The inquest also heard that Ms To had missed several of her competency reviews, an annual requirement for all midwives.

Wiltshire coroner David Masters also seized on the confusion of how drugs were stored in the maternity department following the move to the new GWH site in December 2002.

At the old Princess Margaret Hospital site drugs like Bupivacaine were kept in locked cupboards but at GWH it was stored unlocked alongside intravenous fluids, the inquest heard.

The coroner said: "It seems no-one really grasped the aspect of storage at GWH." Mrs Rattigan again agreed.

Mr Masters added that the move to the new site was "all the more reason why someone should have grasped the issue of storing drugs."