by Maria Sunantha Quibilan/Asianjournal.com
A FILIPINO woman who died shortly after childbirth was found by an inquest jury on Tuesday to have been “unlawfully killed.” Her death resulted from being mistakenly given an epidural through her arm.
Mayra Cabrera, 30, gave birth to son Zac at the Great Western Hospital in Swindon, Wiltshire in western England – the same hospital where she worked as a nurse – on May 11, 2004. She died of a heart attack following the delivery when Bupivacaine, a potent epidural anesthetic meant to be administered to the spine, was wrongly fed into her arm via an intravenous drip. Her son survived.
The jury identified gross negligence by the hospital, particularly the substandard storage of drugs on the maternity unit, as what led to the death.
Arnel Cabrera, Mayra’s husband, was originally informed that an amniotic fluid embolism was the cause of his wife’s death. A year later, after instructing a lawyer to look into the case, he found out that she had in fact died due to a drugs blunder.
Midwife Marie To allegedly came on duty right after Mrs. Cabrera gave birth and wrongly attached Bupivacaine to her IV drip. To, however, denied responsibility and insisted that she thought the anesthetic was either saline solution or a blood volume expander to boost blood pressure.
During the month-long hearing, it was revealed that two other deaths in UK hospitals over the last ten years were caused by the intravenous administration of Bupivacaine.
After an initial police investigation into Cabrera’s death, the hospital administration, Swindon & Marlborough NHS trust, admitted liability, but no criminal charges were filed.
However, after Tuesday’s verdict – the first time in British legal history that an unlawful killing verdict was found against an NHS corporation, and not merely against an individual within the corporation – the prosecution said that it will review the case further after it receives the police files from the inquest.
Lyn Hill-Tout, CEO of the Swindon and Marlborough NHS, in a statement to reporters after the inquest said, “For a tragedy to be caused by shortfalls in care is something for which we are deeply sorry,” she said. “Mayra’s death was avoidable. The verdict reflects that. We have been criticized for a number of failures which we accept, deeply regret and from which we have learned important lessons.”
Mr. Cabrera, although “very satisfied” with the outcome of the inquest, said that reliving the circumstances surrounding the death of his wife felt like “torture.”
He said in a statement: “Mayra was my love and my life. On 11 May 2004 we were overjoyed when our son, Zac, was born. However our life together was ripped apart by the action of a midwife who failed to check the fluid she gave to my wife. She had six opportunities to check this fluid. Had she done so, Mayra would have been alive today.
“The midwife’s failure to accept responsibility or show any remorse for her actions has made me very bitter and angry. I cannot forgive her and now hope that the police and Crown Prosecution Service will prosecute her for manslaughter.
“The inquest has also revealed that the former chief pharmacist (at Great Western Hospital, Swindon) and the Swindon & Marlborough NHS Trust itself must share some of the blame for failing to ensure that the drug Mayra was given was locked away safely.
“I hope and pray that the trust and the NHS will learn lessons from this episode so other patients do not suffer a similar fate to that of Mayra.”
Mr. Cabrera is currently facing deportation from Britain with his son Zac, now three years old, because of the automatic change in his immigration status upon his wife’s death. In 2003, he had been granted permission to stay and work in the country on the basis that his wife was also working there, having been initially recruited by the NHS and coming to the UK in 2002.
He continued in his statement: “I understand that the Immigration Minister, Liam Byrne, has been reconsidering the Government’s decision to deport me and my son from this country, which I have grown to love. It was Mayra’s wish to bring up our son in our newly-adopted country and I hope that the Government will show true compassion as well as honouring Mayra’s memory by righting the wrong that an NHS hospital has done to us.”