A NHS Trust has been fined £75,000 and ordered to pay £25,000 in costs after a mother who had just given birth died when she was given the wrong drug.

Mayra Cabrera, 30, was given an epidural drug in her arm instead of a saline solution. The drug mix up led to medical complications and she died hours later. Wiltshire Police and The Health and Safety Executive (HSE) found that both types of drugs had almost identical packaging and were stored in the same racking system.

Great Western Hospitals NHS Trust pleaded guilty to breaching Section 3 (1) of the Health and Safety at Work etc Act 1974.

Liam Osborne, an HSE Inspector 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 that minimise the chance of human error.”