A woman was unlawfully killed after an epidural drug was fed into her arm via a drip at the hospital in Swindon where she worked.
Mayra Cabrera died shortly after giving birth to her son, Zac, in 2004.
Her husband, Arnel, now faces deportation.
Here is a selection of quotes from those involved.
MAYRA'S HUSBAND, ARNEL CABRERA
Mayra was my love and my life. On 11 May 2004,
we were overjoyed when our son, Zac, was born. However our life together was ripped apart.
The midwife's failure to accept responsibility or show any remorse for her
actions has made me very bitter and angry.
The inquest has also revealed that the former chief pharmacist (at Great Western Hospital) and the Swindon & Marlborough NHS Trust itself must share some of the blame for failing to ensure that the drug Mayra was given was locked away safely.
I hope and pray that the trust and the NHS will learn lessons from this
episode so other patients do not suffer a similar fate to that of Mayra.
It was Mayra's wish to bring up our son in our newly-adopted country and I hope that the government will show true compassion as well as honouring Mayra's memory by righting the wrong that an NHS hospital has done to us.
SWINDON & MARLBOROUGH NHS TRUST
I want to reiterate our sincere and unreserved apologies to Mr Cabrera and his son for the sad death of his wife and son's mother. As soon as trust was aware of the cause of death, we admitted liability. We deeply regret the death.
The inquest has raised a number of important issues and the coroner made a number of recommendations which this trust promises to enact. As soon as Mayra's death was known to us, we put in place a number of actions.
Our prime aim is to ensure that patients have safe care and we are committed to this. One of actions was that the epidural drug was stored in a locked cupboard. Training has been reviewed. We want to make sure all midwives undergo mandatory training.
This case should not have happened and I hope other hospitals will be able to learn from the bitter lessons we have learnt. We will have delivered nearly 4,000 babies safely this year. Safety is always our number one priority.
But one death is one too many. We are an excellent unit and have an excellent record. We can never bring back Mayra but we can do everything in our power to make sure healthcare is safer in the future.
DET INSP IAN SAUNDERS, WILTSHIRE POLICE
Following today's jury verdict of unlawful killing, I will be returning the file and details of the evidence gathered during this inquest to the Crown Prosecution Service for further consideration.
Our thoughts today are with Mayra's family at this sad time. The Wiltshire Police and my investigation team will continue to support them in any way possible."
An individual who does not meet the requirements under the immigration rules can in exceptional circumstances - for instance compassionate reasons - apply for discretionary leave to remain in the UK.
When we receive an application such as this, we would obviously consider all circumstances surrounding the application.
MR CABRERA'S SOLICITOR SEAMUS EDNEY
Mayra's death automatically changed Arnel and Zac's circumstances. We had to go back to the Home Office and ask for permission for Arnel to stay
until 2009, or at least until after his wife's inquest.
We never got a formal reply. We just got his visa back, extended until
The Home Office talks now of exceptional circumstances - but they knew about Arnel's circumstances last year when he made his application to stay until 2009. They are now suggesting he makes another application.
If he does, they will no doubt look at it in three or four months when this
inquest is ancient history - and Arnel will be on his way back to the
For all the setbacks he has had to put up with in the last few years - his
wife is killed by a blunder, then the Crown Prosecution Service decide not to
prosecute anyone, and now he faces deportation - if we can get Arnel permanent
leave to stay in Britain, then at least that will be one positive outcome for
him and Zac.
WILTSHIRE CORONER, DAVID MASTERS
I find it quite extraordinary that this man has not had the comfort of
knowing that he can stay in this country for the foreseeable future.
Because of his wife's death, his reliance upon her work permit has come to an
He is able to make a further application, which I would fully support, had I
any say in the matter, which I do not.
It seems to me that the red tape should be cut and thrown away, quickly,
sooner rather than later.
He should not remain prejudiced in his right to remain in this country
because of the death of his wife, who this jury has found was unlawfully
DEPARTMENT OF HEALTH
We have been doing everything we can to develop a fail-safe connector for Bupivacaine to make it impossible for this to happen again.
But the inquest was told there needed to be an Europe-wide agreement on the connectors.