Manager defends midwife (From The Wiltshire Gazette and Herald)

Manager defends midwife

9:43am Monday 21st January 2008 in Swindon

The midwife on duty when a pregnant woman was given a fatal epidural in her arm instead of her back was defended by her manager at an inquest today as "experienced and competent".

It has been claimed that Marie To, a midwife at Great Western Hospital in Swindon, mistakenly put the Bupivacaine drip into the arm of Mayra Cabrera, 30, who died two hours after giving birth.

Mrs Cabrera, a nurse at the same hospital, suffered a heart attack after being given the anaesthetic while giving birth to her 8lb son Zachary in 2004.

Ward manager Sister Jan Smith this afternoon told an inquest jury in Trowbridge she had "no concerns" about the ability of Ms To.

Sister Smith said: "I checked that she was OK to go back to work."

Gerwyn Samuel, representing Mrs Cabrera's husband Arnel, said: "Did you think that she might require further treatment in the administration of fluids?"

The inquest will resume today, when Ms To will give evidence.

"No - I didn't think to check, but I would have expected her to have identified to me anything that gave her cause for concern," Sister Smith said.

"She was an experienced and competent midwife who worked within the delivery suite and has a lot of experience.

"I had no concerns for her. Her practice had never come to my attention."

She added: "There was no proof that Marie To did it, so I couldn't discipline her."

She said she did not carry out her own investigation, because there was an ongoing inquiry at a more senior level.

Mrs Smith also confirmed Ms To had been given bereavement counselling after the incident.

On the previous day the court was told there were up to three potentially fatal drug mix-ups by the NHS trust's midwives before a fourth led to the woman's death.

Mrs Cabrera, who moved to Swindon from the Philippines in 2002 to work as a theatre nurse at GWH, died of Bupivacaine toxicity on May 11, 2004.

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.

Describing it as "an atrocious failure", the barrister asked Christina Rattigan, the head of midwifery: "It is an abysmal state of play, is it not, to find one of your 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".

Wiltshire Police investigated the death but a decision was later taken by the Crown Prosecution Service not to charge anyone.

The inquest will resume today, when Ms To will give evidence.