The Pharmaceutical Journal
Vol 280 No 7490 p206
23 February 2008

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Criminal charges reconsidered after epidural error

Criminal charges are to be reconsidered by the Crown Prosecution Service following an inquest jury’s verdict that a woman who died at Swindon’s Great Western Hospital in 2004 was unlawfully killed after a midwife mistakenly gave her an intravenous infusion of bupivacaine, intended for epidural injection, instead of saline.

A year ago, the National Patient Safety Agency issued a patient safety alert advising hospitals to keep solutions intended for epidural use separate from intravenous solutions, although it is too early to say what impact this alert may have on hospital practice. The NPSA said that implementation of the advice should be led by hospital chief pharmacists.

After Mayra Cabrera, an operating theatre nurse at the hospital, died, Wiltshire police sent a file to the CPS, which decided that there was insufficient evidence to bring charges against anyone and the case was referred to the Wiltshire coroner for an inquest.

An inquest jury said earlier this month that gross negligence by Swindon & Marlborough NHS Trust led to Mrs Cabrera’s death, specifically blaming what it called “chaotic storage of medicines” in the hospital’s maternity unit.

As a result, Wiltshire police are now to return the file to the CPS with the verdict for reconsideration. The inquest heard that there had been two previous deaths from a similar cause at other hospitals and that after one of them, in 2001, a memo had been circulated by the trust to say that epidural bupivacaine should be stored separately from intravenous infusions.

That policy had been implemented at the old Princess Margaret Hospital, but it was not continued when services relocated to the new Great Western Hospital.

The chief pharmacist at the time, now retired, had assumed that the storage policy would be carried forward after the move, the inquest heard.

The NPSA has no figures for the number of incidents involving epidural injections reported since the safety alert was issued in March 2007 but it plans to check compliance with the alert this summer, when it will be sending out an audit form to all trusts in England and Wales.

The NPSA is also reviewing information from the Department of Health’s safety alert broadcast system (SABS), which enables it to identify which trusts in England have received the alert and what action they have taken.