A HOSPITAL trust has been ordered to pay £100,000 today after a mother, who had just given birth in Swindon's Great Western Hospital, died due to a mix-up between "identical-looking" drugs.

Mayra Cabrera, 30, died hours after giving birth to son Zac, who survived, at the GWH on May 11 2004.

A nurse wrongly attached the epidural anaesthetic Bupivacaine to an intravenous drip attached to her arm instead of saline solution which she needed to help bring her blood pressure back up.

Mrs Cabrera - who was a nurse at the same hospital - died within minutes from a heart attack caused by the toxic effects of Bupivacaine.

The two drugs had "almost identical packaging" and her life could have been saved if the bags were kept in separate cupboards, the Health and Safety Executive said today.

The Great Western Hospitals NHS Foundation Trust was ordered to pay £75,000 in fines and £25,000 in costs by a judge at Bristol Crown Court.

The Trust had pleaded guilty to an offence under the Health and Safety at Work Act.

Passing sentence today, Mr Justice Clarke said: "No one could be unmoved by this tragedy. No one who knew what lay behind it could be untroubled at the systematic and individual fault which this inquiry revealed."

The midwife, who was suspended and is now retired, "could not have read the label carefully or possibly at all", he added, also citing the inadequate drugs storage as a factor in Mrs Cabrera's 2004 death.

An inquest at Trowbridge, Wiltshire, two years ago ruled that Mrs Cabrera was unlawfully killed, also citing the "chaotic" drug storage.

Mrs Cabrera gave birth to son Zac at 8.14am on May 11, 2004. She began to suffer a fit and at 10.27am she was certified dead.

The Health and Safety Executive (HSE) said after today's fine that the "heartbreaking case" showed there was no proper system for the storage of the drugs at the time.

A similar mistake in 2001, which did not result in death, had not served as a sufficient warning to prevent the tragedy.

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 to minimise the chance of human error."

The case was made more tragic because Mrs Cabrera used to work as a nurse for the same hospital, he added.

Her widower Arnel Cabrera has now returned to their native Philippines and was raising their son Zac with the help of relatives.

He said in a statement today: "It has been six years since my wife Mayra died and two years since the inquest into her death was concluded.

"I would like to thank the HSE for bringing this prosecution and I am pleased with its outcome.

"It reinforced the importance of the heath and safety of patients attending hospital and in particular the safe storage of dangerous drugs.

"Now this case has concluded, I am hoping my young son and I can have some closure and put this terrible tragedy behind us."