Mum's death hangs over hospital

This followed the death in 2004 of Mayra Cabrera at Swindon’s Great Western Hospital just hours after giving birth to her son Zac. The trust had pleaded guilty to an offence under the Health And Safety At Work Act and the court head that Mrs Cabrera died due to a mix-up between “identical-looking” drugs. The trust and the hospital has come under criticism at Monday’s hearing and at an inquest into Mrs Cabrera’s death.

Health reporter HAYLEY COURT visited GWH’s maternity unit to find out what lessons have been learned since the tragedy.

SIX years may have gone by but the shadow of what happened to Mayra Cabrera still lingers in the busy maternity unit at Great Western Hospital.

For midwives so used to bringing life into the world, the sadness at one cut so tragically short will never leave them.

“It would be easy for anyone on the outside to say, it was just one person,” said senior midwife Sandy Richards.

“But how can they mean that? One is enough – it’s too many. That one loss still hangs over us today. We will never forget what happened that day and six years on it is still very much in our minds.”

The maternity unit did not grind to a halt the day Mayra died. Instead staff brushed themselves down and continued the job in hand – to deliver a handful of the 300 babies born at Great Western Hospital every month.

But the memories of that dreadful day still echo throughout the unit.

“For me, the bottom line is that someone died here. That will never be forgotten,” said Mrs Richards.

“The effects of it cannot be underestimated with the staff. They all come to work to do the best and safest job possible. After it happened, we didn’t shut the unit, we had to provide the service the same day and the next day and the next day.

“The effects are still being felt now, six years down the line.”

Following the tragedy, the storage of bupivacaine at Great Western Hospital was changed immediately, leading the way for national clinical guidelines which were implemented in early 2007.

“What happened did make us re-evaluate certain processes and procedures,” said senior midwife Alison Morton.

“We make sure all the systems and processes are the best they can be.”

Mrs Richards added: “We have sat in on conferences where it has been discussed in front of us at a regional level which has been difficult. But we have contributed our experiences so that no one ever has to go through it.”

The dedication of the staff at GWH’s midwifery unit has not gone unrecognised.

The Healthcare Commission, an independent inspection body for both the NHS and independent healthcare, now rates Great Western Hospital’s maternity unit one of the best performing in the country.

Since a 12-point improvement plan was laid out by Wiltshire Coroner David Masters at the conclusion of the inquest into Mayra’s death, the hospital has been in the top 25 per cent of maternity units in the country and Babyworld parents’ website voted it in the top five hospitals to give birth in.

The unit also earned 2010’s National Health Service Litigation Authority level three rating, the highest rating for the safety of service offered by the hospital.

The NHSLA, a body that conducts rigorous independent assessments against a number of risk management standards, inspected GWH’s maternity unit in December 2008 against new standards then being piloted by the NHSLA.

It was awarded the highest level standard, and at that time was one of only two trusts in the country to achieve it.

In December 2009 the maternity unit at GWH was awarded the first ever Shine Award by the Health Foundation for improvements and innovation in antenatal care for women with complex pregnancies.

“We’d never want to be complacent and I would never say we are proud of what we have achieved since that day,” said Mrs Richards.

“Proud is the wrong word. Nothing will ever change the fact that someone died here but I am reassured for us as a unit that we are doing everything to make it as safe as possible.”