Great Western Hospitals NHS Foundation Trust were prosecuted by the Health & Safety Executive (HSE) after Mayra died at Great Western Hospital in Swindon on the 11 May 2004. Mayra, who was also a nurse at the hospital, was given an epidural drug in her arm instead of saline solution. She died an hour later following medical complications caused by the drug mix-up. Investigations by the HSE and Wiltshire Police showed that the two drugs were stored in the same racking system, despite having almost identical packaging.

On the 17 May 2010, Bristol Crown Court fined the Hospital Trust £75,000.00 after they admitted breaching Section 3 (1) of the Health and Safety at Work etc Act 1974 by putting the safety of patients, including Mayra at risk due to the unacceptable storage of drugs and the administration of drugs. The Hospital Trust were also ordered to pay costs of £25,000.00.

Mayra had just given birth to her first child, a boy, when she was wrongly given a rarely-used local anaesthetic, bupivacaine. She had been prescribed a saline solution to help raise her blood pressure, but instead the bupivacaine was selected due to a mix-up.

The consequent Police and HSE investigations showed that there was no proper management system for the storage of the drugs, and warnings from earlier incidents had not been properly dealt with.

Speaking after the hearing, HSE Inspector, Liam Osborne, said:-

“This was an absolutely heartbreaking case to investigate. Mayra Cabrera needlessly died as a result of comprehensive management failings at board, pharmacy and ward level.

Had the hospital done something as simple as keeping these completely different but almost identical-looking drugs in separate cupboards then Mrs Cabrera would not have died.

It is really important that risks are properly assessed and safe systems put in place that minimise the chance of human error.

The organisational failure to assess the risks and provide a safe system for the storage of these products placed any patient in the in the Maternity Unit at risk, from when the Great Western Hospital opened in December 2002, until the drugs were removed after Mrs Cabrera died in 2004.

The Trust failed in its duty of care to Mrs Cabrera, and the fact that she used to work for the hospital that ultimately ended her life makes this all the more tragic”

Mayra’s widower, Arnel Cabrera, issued a press release through our firm which said:-

“It has now been six years since my wife, Mayra died and two years since the Inquest into her death was concluded and I would like to thank the HSE for bringing this prosecution and I am pleased with its outcome. It reinforces the importance of the health and safety of patients attending the hospital and in particular the safe storage of dangerous drugs. Now this case has been concluded I am hoping that my young son and I can have some closure and put this terrible tragedy behind us”.

The HSE is Britain’s national regulator for workplace health and safety. It aims to prevent death, injury and ill health. It does so through research, information and advice, promoting training new or revise regulations and codes of practice, and working with local authority partners by inspection, investigation and enforcement –



It was reported in the Times on the 14 June 2010, that Lord Young of Graffham, a former Government Minister, would examine the laws’ contribution to the so-called “compensation culture”. He was appointed by the Prime Minister. Lord Young will “investigate concerns over the application and perception of health and safety legislation together with the rise of the compensation culture over the last decade”.

He will report by the summer and work with Government departments to implement his proposals.

We at S J Edney are getting very tired of this constant whinging about the so-called “compensation culture” in the UK. All the evidence available suggests that no such culture exists. We can provide our readers with details of two cases which we have recently which reinforces the importance of health and safety legislation namely:-

  • We were acting for a middle aged woman, working in a sandwich factory in Swindon, who due to a defective machine, lost three of her fingers on her dominant right hand. These not only prevented her from returning to work but the shock of the accident has caused her to become almost a recluse. She will never recover from this accident.
  • Another client, an elderly lady aged 88, was allowed to fall out of her wheelchair, whilst being taken by ambulance from her home to hospital for a routine appointment. As a consequence, she broke her sternum in two places. She had to stay in hospital for treatment and even on her return home, she still needs a great deal of support from her family as these injuries have in effect caused her to lose her independence. The accident could have been avoided if she had been properly strapped into her wheelchair by the driver of the ambulance.

These two cases are typical of those cases which we are currently working on at S J Edney. Health and Safety legislation exists not to prevent children from playing conkers at school but to safeguard employees at work and patients from horror stories like those reported above. The HSE and other organisations that promote health and safety should be congratulated for the work they do not maligned by politicians looking for an easy target or tabloid editors hoping for a headline to sell newspapers. We do not understand why those people concerned with avoiding unnecessary injuries or waste of life should have such a poor press.


5 Tips for a Healthy & Safe Workplace

In our view, prevention is always much better than cure. We can provide the following 5 tips to an employer to minimise the risk of one of their employees having an injury at work namely:-

  1. Assess the risks – decide what could harm people and what precautions should be taken. An employer must act on the findings of their risk assessment by putting sensible controls in place to prevent accidents and ill health and it is important to make sure that these safeguards are followed.
  2. Write your own health and safety policy – the HSE website gives an employer guidance on what to include in their policy. It is important that an employer also explains to their staff the arrangements that they have put in place for managing health and safety at their firm.
  3. Take out employers liability insurance – this covers a claim from an employee who could be injured or become ill as a result of their work.
  4. Keep an Accident Report book – this will record details of any accidents that have taken place.
  5. Make sure that you regularly review the health and safety policy and risk assessments and ensure that all your employees understand their roles and responsibilities.

Congratulations to Seamus Edney

Everyone at S J Edney would like to congratulate Seamus on completing the London Marathon during April 2010 and in the process raising £2k for Headway and more recently for completing the 3 Peaks Challenge in less than 24 hours and raising some £500.00 for Help for Heroes. We suspect that this may be part of his midlife crisis and we are all wondering what his next challenge might be. Climbing Mount Everest!?!

This newsletter was produced by S J Edney solicitors Telephone: 01793 600721

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