A succession of drugs mix-ups by midwives led to a woman's death, an inquest jury has heard.
Mrs Cabrera's son survived
The hearing heard how an epidural anaesthetic was mistakenly given to 30-year-old Mayra Cabrera, via an intravenous drip, in hospital.
Nurse Mrs Cabrera, who came to Swindon from the Philippines in 2002, died of Bupivacaine toxicity in May 2004.
Christina Rattigan, head of midwifery at Great Western Hospital (GWH), agreed policy breaches had taken place.
Ms Rattigan admitted there had possibly been a similar mix-up with Bupivacaine in 1994, although her recollection was sketchy.
Gerwyn Samuel, representing Mrs Cabrera's husband, told the court that in 2001 there were two other non-fatal incidents - one involving Bupivacaine - where epidural drugs were wrongly set up for intravenous infusion.
These three incidents took place at the former Princess Margaret Hospital, replaced by GWH in 2002.
A note distributed around GWH by its chief pharmacist asked staff to ensure Bupivacaine was clearly marked and stored separately from intravenous drugs.
But the inquest heard this failed to happen until after Mrs Cabrera's death. Mrs Cabrera died after giving birth to her son Zac, who survived.
Wiltshire Police investigated the death but a decision was later taken by the Crown Prosecution Service not to charge anyone.
The hearing continues.