YOUNG MOTHER DIES AFTER HAVING EPIDURAL IN HER ARM
This case has been widely reported both in the local and national media.
It concerns the very sad case of Mrs
Mayra Cabrera who died within 1½ hours after giving birth
to her child in May 2004 at Great Western Hospital (GWH) in Swindon.
Mayra (who came from the Philippines) became pregnant in 2003. She was admitted to the delivery suite of GWH on the 10 May 2004. The first and second stages of labour proceeded without incident. She eventually gave birth to a boy on the 11 May 2005.
During the course of the perineal repair, she became dizzy, started fitting and eventually arrested. Resuscitation attempts were sadly unsuccessful. It later transpired that her death was caused by an accidental intravenous infusion of bupivacaine, a very potent anaesthetic into a vein in her right hand. This should only have been given in small doses as an epidural into the epidural space of the spinal cord.
The Hospital Trust have admitted liability and apologised to Mrs Cabrera’s family for what happened. To compound matters, she was a Nurse at GWH and not surprisingly her death has had a huge impact on both her colleagues and friends at the hospital. It is a shame however that no member of staff has admitted to making this error.
A pre-hearing Inquest was held into her death in November 2005 but it was adjourned to enable the Police to investigate the circumstances surrounding her death. Surprisingly, the CPS confirmed that no one would be prosecuted.
We pressed for the following questions to be answered at this hearing:-
1. How did this terrible error come to happen? – it is even more remarkable because the bag of anaesthetic was clearly marked with the words “For epidural use only”;
2. What lessons can be learnt by both the Hospital Trust and the Department of Health to ensure that this type of error does not happen again in the future – epidurals are commonly used during childbirth to provide pain relief and women need to be reassured that systems are in place to minimise the risk of this mistake being made again;
3. Further, it is important to find out why there was delay in the Hospital
Trust acknowledging that this mistake had been made. Mrs Cabrera’s
husband returned to the Philippines shortly after her death believing
that she had died from natural causes. He only learnt that something
had gone wrong over a year later after we wrote to the hospital. In
our view, the Hospital Trust failed in their duty of candour to Mr Cabrera.
Latest report - Thames West TV Media clip 05/02/2008
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