A midwife has denied making a medical error which resulted in the death of a 30-year-old woman.
Mayra Cabrera died at Great Western Hospital in Swindon on 11 May 2004 from Bupivacaine toxicity after an epidural was allegedly placed in her arm, rather than her spine.
But Sister Marie To told Trowbridge Coroner’s Court she used a drip containing the blood pressure drug Gelafusin or saline, and definitely not the anaesthetic.
But barrister Malcolm Fortune, representing the Swindon & Marlborough NHS Trust, said she made a “grossly negligent” mistake.
He added: “You cannot accept, or will not accept, that you put Bupivacaine up, which caused Mrs Cabrera’s death.”
However, Mrs To replied: “I did not choose Bupivacaine.”
Wiltshire Coroner David Masters also observed that the midwife did not mention the Gelafusin drip on Mrs Cabrera’s chart.
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 has admitted liability for the mistake. Wiltshire Police investigated the incident but the Crown Prosecution Service decided not to charge anyone.
The inquest continues.
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“I would like to comment on the gravity of this mistake by a senior nurse. It is not uncommon for senior staff complacent of their nursing practice to be unchallenged because of their seniority. On the other hand, it should be nursing practice to check any drug of any delivery method, especially via the intravenous or epidural route, and for this to be witnessed at all times prior to administration and followed with monitoring of vital signs. There was no excuse; if it was a junior nurse’s fault, I’m sure there was no hesitation to suspend or sack the nurse. It is about time midwives or obstetric nurses are trained in epidural monitoring or have an intravenous administration competency update.” – PACU senior specialist nurse.
“Someone needs to be punished for this incident. Marie To should know the protocol for giving IV infusion. And her statement “that was because I was not sure if it was Gelafusin or saline” only means that she is not competent to continue working as a midwife.” – Name and contact details supplied.
“How can a senior nurse be allowed to administer ANY drug without recording it? This sounds like a hospital cover-up to protect themselves for employing an imcompetent midwife.” – Name and contact details supplied.