Midwife denies blaming doctor (From The Wiltshire Gazette and Herald)

Midwife denies blaming doctor

2:05pm Tuesday 22nd January 2008 in Swindon

A midwife today denied that she is trying to blame a doctor for her own alleged blunder which led to the death of a new mother.

Sister Marie To is said to have mistakenly put up an intravenous drip containing Bupivacaine, a potent epidural anaesthetic.

The recipient, Filipino theatre nurse Mayra Cabrera, 30, died from Bupivacaine toxicity less than three hours later on May 11 2004, after giving birth to surviving son Zac at Great Western Hospital in Swindon.

Mrs To told Mrs Cabrera's inquest in Trowbridge that she believes - bucannot be certain - that she put a drip of Gelafusin, a blood volume expander to boost blood pressure, or possibly saline solution, but definitely not Bupivacaine.

She claims that after putting the drip bag up she tried to get it double-checked, in accordance with NHS protocols, by Dr Gourab Misra but, she says, he was in a rush and so it did not happen.

Malcolm Fortune, for the Swindon & Marlborough NHS Trust, put it to Mrs To: "Late in the day, having seen Dr Misra's statement, you have chosen to blame Dr Misra.

"You are seeking to besmirch the reputation of a senior doctor in these circumstances, aren't you?"

"No," Mrs To said.

Mr Fortune said the midwife breached NHS guidelines by firstly putting up the bag without getting the bag double-checked by another person, and secondly by starting the flow.

Mr To said: "All I know, Sir, is that I did my best to check. As I said, he was too quick for me."

Mr Fortune disagreed: "This just is not true, is it? This is not a truthful account of what happened. You will not face the reality that you put up Bupivacaine - is that not correct?"

She replied: "I did not put up Bupivacaine, Sir."

The barrister, describing the error as "grossly negligent," said: "You cannot accept, or will not accept, that you put Bupivacaine up, which caused Mrs Cabrera's death."

"I did not choose Bupivacaine," came the reply.

Wiltshire Coroner David Masters voiced concern over Mrs To having added to Mrs Cabrera's drug chart notes after her death - something that should not happen.

He also observed that she did not mention on the chart that she put up a Gelafusin drip - something she has told the inquest she did.

Mrs To said: "That was because I was not sure if it was Gelafusin or saline."

The coroner replied: "You are telling me on oath are you that that was the reason you made no record?"

"Yes," she said.

Swindon & Marlborough NHS Trust have admitted liability for the error.

Police investigated but the Crown Prosecution Service decided not to charge anyone.