A woman who died after mistakenly being given an epidural in her arm during childbirth was unlawfully killed, an inquest jury ruled on Tuesday.
Mayra Cabrera, 30, a theatre nurse from the Philippines, died soon after giving birth to her son at Great Western Hospital in Swindon in May 2004. The baby survived.
Midwife Marie To denied she was responsible for administering the drug Bupivacaine into Cabrera's arm.
She had said she thought it was either saline solution or Gelofusine, a blood volume expander to boost blood pressure, the BBC reported.
An epidural, an anaesthesia, is administered to the spine.
The coroner's jury said poor storage of drugs on the maternity unit amounted to gross negligence by the health trust, which led to the death.
Swindon and Marlborough NHS Trust had earlier admitted liability for the death.
In a statement to reporters after the inquest in Trowbridge, Lyn Hill-Tout, chief executive for the health trust, said: "For a tragedy to be caused by a shortfall in care is something we deeply regret.
"This tragic case should not have happened. I sincerely hope other hospitals and maternity units like ours will be able to learn from the bitter lessons that we have learnt."
Coroner David Masters said he will be making recommendations to the government on how to improve storage of potentially dangerous drugs in hospitals.
Cabrera's death has led to a cruel twist in her husband's legal status in Britain.
Arnel Cabrera has been told he is not allowed to stay now his wife no longer works in the country.
He told reporters outside the court: "It was Mayra's wish to bring up our son in her 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 NHS hospital has done to us."
The Home Office said it could not comment on individual cases, but a spokeswoman said: "An applicant, who does not meet requirements under immigration rules, can in exceptional circumstances apply for discretionary leave to remain in the UK.
"We need to receive an application through for us to consider it."
The Crown Prosecution Service, which initially said there were no criminal charges to be filed in the death of Mayra Cabrera, said it will review the case after it received police files from the inquest.
