THE chief executive of the Great Western Hospitals NHS Trust today offered an apology to Mayra Cabrera’s family.

Speaking after the trust was ordered to pay £100,000 following the death of the 30-year-old Filipina midwife just hours after giving birth to son Zac six years ago, Mrs Hill-Tout said that lessons had been learned by the tragedy.

She said: "I want to apologise again to Mr Cabrera, his son, family and friends for the mistakes that happened which led to Mrs Cabrera's death.

"As a result of what happened, a husband does not have a wife and a son does not have a mother.

"We deeply regret this - Mayra's death should not have happened.

"Since her death the Trust has co-operated with six external inquiries and a jury inquest which lasted four-and-a-half weeks.

"We have implemented all of the recommendations from the inquiries and the inquest.

“The improvements made to the maternity service since Mayra's death led to the Care Quality Commission awarding the hospital the best standard for maternity care.

"Regrettably, we cannot turn the clock back. However, we have learnt valuable lessons and will never again be complacent about patient safety by ensuring it remains our top priority at all times."

Mrs Cabrera's month-long inquest in 2008 was told how the hospital's storage methods failed to meet NHS requirements stating that drugs like Bupivacaine should be stored in locked cupboards separately from intravenous fluids.

There had been two other deaths at hospitals in the UK in the past decade caused by Bupivacaine being administered intravenously, coroner David Masters heard.

Soon after one - that of 74-year-old Philip Silsbury in 2001 at Royal Sussex County Hospital - a memo was sent round Swindon & Marlborough NHS Trust advising that Bupivacaine be kept separately from intravenous drugs to lessen the chance of a mix-up.

At the time the hospital was at its old Princess Margaret Hospital (PMH) site in Swindon, prior to its December 2002 move to GWH.

Stephen Holmes, the now-retired chief pharmacist at GWH, sent the memo on correct Bupivacaine storage around the PMH in 2001.

He was told at the time by staff that this had in fact been the hospital's practice since 1995.

However, these storage standards were not carried over to the new GWH site, with epidural drugs stored alongside intravenous ones.

It was not until after Mrs Cabrera's death that drug storage was brought up to standard.

David Masters, the coroner for Wiltshire, describing the situation as "chaotic", said: "It seems no-one really grasped the aspect of storage at GWH."

He said the move to the new site was "all the more reason why someone should have grasped the issue of storing drugs".

Malcolm Fortune, for the NHS trust, argued that, chaotic drug storage or otherwise, the main blame lay with the person - midwife Marie To - who had attached the bag to the drip without properly checking the contents label - "Bupivacaine: For epidural use only".

Had Ms To gone through all the checks required of her by NHS midwifery protocols, which include getting a doctor to verify the drip bag, Mrs Cabrera would be alive today, he said.

She had denied attaching Bupivacaine to the drip.

The inquest heard there had been three previous non-fatal drug mix-ups involving epidural drugs being attached to intravenous drips at the PMH before the one that caused Mrs Cabrera's death.

One involving Bupivacaine was in 1994, while in 2001 there were two others, one of which involved Bupivacaine.

Alfred Tinwell, 84, died in 2000 at Royal University Hospital, Liverpool, after he was mistakenly given Bupivacaine intravenously.