About 45 minutes following childbirth, Mayra Cabrera began to feel dizzy and faint and she was put under observation. She then began fitting and suffered a cardiac arrest. Resuscitation attempts were implemented but sadly unsuccessful. Within 2 hours of giving birth to her son, she had died. Her husband had been in the room as the doctors fought in vain to save her life.
Whilst resuscitation was being attempted on Mayra, medical staff noted a 500mls bag of Bupivacaine (a potent epidural anaesthetic) which had been wrongly connected to a cannula and inserted in her right arm. Bupivacaine should only be administered to a patient epidurally (for pain relief) and not into the blood intravenously. This drug had been wrongly hooked up to Mayra’s drip instead of a saline solution.
Later examination of the bag indicated that Mayra must have been given between 100mls and 150mls of this solution intravenously, enough to kill her. The Pathologist in his post mortem examination concluded that she had died from Bupivacaine toxicity. Notwithstanding the Post Mortem report, Arnel had been told that his wife had died from natural causes. As a consequence of her death, Arnel had no option but to return to the Philippines in June 2004; since his residency status in the UK depended on his wife being alive and working, he was no longer able to work. In May 2005, our firm was instructed by Arnel (through a friend in Swindon) to investigate the circumstances surrounding his wife’s death.
In July 2005, the Hospital Trust wrote to our firm and confirmed that Mayra’s death was caused as a direct result of a mix-up of the drugs in the maternity department which had caused her to be given an excessive and lethal dose of Bupivacaine. They were prepared to admit liability in any future civil claim. It is disappointing that the real reason for Mayra’s death only came to light some 14 months after she died and, not surprisingly, this came as a complete shock to her husband.
A Jury Inquest took place into the death of Mayra Cabrera over a period of four weeks at the beginning of 2008. The Inquest closely examined how the Bupivacaine came to be administered by a midwife in error. Arnel, the Hospital Trust, the Midwife who administered this drug and the Health & Safety Executive were all represented. A number of the hospital staff who treated Mayra and independent medical experts attended to give oral evidence.
What became clear during the Inquest is that Mayra’s death was not a “one-off” accident. It appears that there have been at least two other fatal accidents in the NHS where epidural infusions of Bupivacaine were administered intravenously in error – these are described by the NHS as “wrong route drug errors”. Both these deaths pre-dated Mayra’s death in 2004. Recommendations were made by the Coroners in these cases to the Department of Health, in an effort to avoid this type of tragedy occurring again and, as a result, the National Patient Safety Agency came into being. It was clear during the course of the Inquest that wrong route drug errors continue to take place regularly within the NHS despite the preventative checks that are in place.
In addition, the following evidence also came to light during the Inquest:
- there were also two other “near misses” at old Princess Margaret Hospital in Swindon involving the intravenous administration of Bupivacaine, once in 1994 and on a second occasion during 2001;
- a policy was introduced by the Hospital to keep Bupivacaine stored in a locked cupboard and separate from the intravenous fluids but unfortunately this policy was discarded on their move to GWH in 2002
- the Midwife who made this catastrophic blunder (she had at least six opportunities to check this fluid before administering it to Mayra) was not disciplined or placed under any supervision by the Hospital following Mayra’s death. During the course of her evidence at the Inquest, she did not publicly acknowledge that she had made an error. She has shown no remorse for what she did, which has been very upsetting for Arnel Cabrera.
On 4th February 2008, after some 17 hours deliberation, the Jury returned a majority verdict, namely a verdict of unlawful killing against the individual midwife for gross negligence by reason of her administration of this drug, and also against the Hospital for corporate gross negligence manslaughter by reason of their unsafe storage of Bupivacaine at GWH.
The unlawful killing verdict against the Hospital Trust is a landmark decision. It is believed to be the first such finding against an NHS Trust rather than a named individual. Following the Inquest, GWH apologised unreservedly for the mistakes which had been made and say that they had learned its lesson. They would now take steps to prevent the re-occurrence of what had happened to Mayra.
The Coroner (Mr David Masters) said that he would be writing to the Department of Health, the Midwifery Council, the relevant Royal Colleges and the General Medical Council recommending that staff training and the storage and administration of drugs should be overhauled. He also wants the connectors for epidural drugs to be changed so that a mix-up would be unlikely to reoccur in the future.
To add to the travesty of justice in this case, Arnel’s leave to remain in the UK was due to expire at the end of February 2008. He had only been given temporary leave to stay in the UK pending the conclusion of the Inquest. We have submitted a further application to the Home Office for permission for Arnel to remain indefinitely in the UK on compassionate grounds. Our request has been backed by the Coroner who criticised the way in which Arnel’s case had been dealt with by the Home Office until now.
Arnel has shown great fortitude and courage during recent years and we at S J Edney all hope that his case will have a happy outcome. It was Mayra Cabrera’s wish to bring up her son in their newly adopted country and we hope that the Government will show true compassion, as well as honouring Mayra’s memory, by righting the wrong which an NHS Hospital has done to Arnel and his family.