A theatre nurse who died after wrongly having a drug used in epidurals pumped into her arm was unlawfully killed, an inquest jury has ruled.
Mayra Cabrera, 30, died shortly after giving birth to son Zac at the Great Western Hospital, Swindon, on 11 May 2004. The baby survived.
Midwife Marie To is alleged to have administered the drug Bupivacaine but denied this in evidence.
Swindon & Marlborough NHS Trust had previously admitted liability.
The jury said gross negligence by the trust, specifically sub-standard storage of drugs in the maternity unit, had led to the death.
A spokeswoman for the trust apologised after the inquest, adding: "This case should not have happened and I hope other hospitals will be able to learn from the bitter lessons we have learnt."
'Bitter and angry'
Coroner David Masters made a number of recommendations - which the trust said it would enact - including better labelling of drugs and enforced annual appraisals for midwives.
Mrs Cabrera, who came to Swindon from the Philippines in 2002, died from a heart attack caused by Bupivacaine toxicity.
The drug should be administered via an epidural but was instead pumped through a drip attached to her arm.
"His wife is killed by a blunder, then the Crown Prosecution Service decide not to prosecute anyone, and now he faces deportation"
Her 38-year-old husband Arnel now faces deportation to the Philippines.
After the inquest Mr Cabrera, who was originally told his wife had died from an amniotic fluid embolism, told a press conference: "Our life together was ripped apart by the action of a midwife who failed to check the fluid she gave to my wife.
"The midwife's failure to accept responsibility or show any remorse for her actions has made me very bitter and angry. I cannot forgive her."
Mrs To, who retired last year, came on duty just after the birth and is alleged to have attached Bupivacaine to Mrs Cabrera's drip.
She denied having done so, insisting she thought it was either saline solution or Gelofusine, a blood volume expander to boost blood pressure.
Counsel for Mrs To said the verdict was a British legal landmark - the first unlawful killing verdict found against an NHS corporation, as opposed to a named individual within one.
In a statement issued through her solicitors, Mrs To said: "My client wishes to extend her deepest and heartfelt sympathies to the Cabrera family following this tragedy."
The trust said it had carried out an investigation into the death which had apportioned no blame, and the findings as to exactly what had happened were inconclusive.
Police investigation
Detective Inspector Ian Saunders, of Wiltshire Police, said he would now be referring the case to the Crown Prosecution Service.
"Our thoughts are with Mayra's family at this sad time," he added.
Mrs Cabrera's job as a nurse at the hospital where she died, and where her husband also worked, was the reason the couple had been granted leave to stay until 2009.
Her husband's immigration status has changed since Mayra's death and his visa had been extended only until the end of February.
CORONER'S RECOMMENDATIONS
Seamus Edney, Mr Cabrera's solicitor, added: "For all the setbacks he has had to put up with - 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, then at least that will be one positive outcome."
The coroner also backed the call for Mr Cabrera to stay in the UK.
A spokesman for the Home Office said: "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."
The couple's son Zac has been looked after in the Philippines over the past few years as his father prepares to pursue a civil claim against the NHS trust.
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