More drug errors revealed at inquest (From Swindon Advertiser)

More drug errors revealed at inquest

8:18pm Thursday 17th January 2008 in News

THE list of drug blunders prior to Mayra Cabrera's death has risen again.

On day nine of the inquest it was revealed that there were up to three potentially fatal drug errors at the Great Western Hospital and its predecessor, Princess Margaret Hospital, before a fourth claimed 30-year-old Mayra's life.

Christina Rattigan, head of midwifery at GWH, agreed that Swindon & Marlborough NHS Trust policy had been breached on a number of occasions leading up to Mayra's death on May 11, 2004.

The jury sitting at Trowbridge Coroner's Court heard how Bupivacaine, a powerful epidural anaesthetic, was given to Mayra in her hand rather than in her spine.

Filipino-born Mayra came to Swindon with husband Arnel, 38, 2002.

She worked as a theatre nurse at GWH with Arnel working as an IT technician.

The pair soon discovered they were expecting their first child but just one hour after baby Zac's birth his mother suffered a horrific seizure and died.

Two pathologists recorded the cause of Mayra's death as Bupivacaine toxicity.

Mrs Rattigan yesterday said there had possibly been a similar mix-up with Bupivacaine in 1994, although her recollection was sketchy.

Gerwyn Samuel, representing widower Arnel, told the court that in 2001 there were two other non-fatal incidents within just one month of each other.

One involved Bupivacaine - where epidural drugs were wrongly set up for intravenous infusion and another involved a powerful labour-inducing drug known as Syntocinon.

All three incidents took place at the former Princess Margaret Hospital in Okus, which was replaced by GWH in 2002.

Also in 2001, a memo was sent to hospitals around the country following the death at Royal Sussex County Hospital of Philip Silsbury, 74, of Littlehampton, West Sussex, after he too was mistakenly given Bupivacaine intravenously.

A note distributed by GWH chief pharmacist Steven Holmes asked staff to ensure Bupivacaine was clearly marked and stored separately from intravenous drugs.

But although the practice was eventually implemented at Princess Margaret Hospital staff failed to carry it over to the GWH until after Mrs Cabrera's death.