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The Great Western Hospital trust has been ordered to pay £100,000 after a young mother died due to a mix-up with drugs.
Mayra Cabrera, 30, died hours after giving birth to son Zac, who survived, at Swindon's Great Western Hospital in May 2004.
A nurse wrongly attached the epidural anaesthetic Bupivacaine to an intravenous drip attached to her arm instead of saline solution needed to bring her blood pressure back up.
Mrs Cabrera - who was a nurse at the same hospital - died within minutes from a heart attack caused by the toxic effects of Bupivacaine.
The two drugs had "almost identical packaging" and her life could have been saved if the bags were kept in separate cupboards, the Health and Safety Executive said.
The Great Western Hospitals NHS Foundation Trust was ordered to pay £75,000 in fines and £25,000 in costs by a judge at Bristol Crown Court.
The Trust had pleaded guilty to an offence under the Health and Safety at Work Act.
Passing sentence, Mr Justice Clarke said: "No one could be unmoved by this tragedy... (or) be untroubled at the systematic and individual fault which this inquiry revealed."
The midwife, who was suspended and is now retired, "could not have read the label carefully or possibly at all," he added.
He also cited the inadequate drugs storage as a factor in Mrs Cabrera's death.
An inquest at Trowbridge, Wiltshire, two years ago, ruled that Mrs Cabrera was unlawfully killed, also citing the "chaotic" drug storage.
Mrs Cabrera gave birth at 8.14am on May 11. She began to suffer a fit and at 10.27am she was certified dead.
Her widower, Arnel Cabrera, has now returned to their native Philippines and is raising Zac with the help of relatives.
He said in a statement: "I would like to thank the HSE for bringing this prosecution and I am pleased with its outcome.
"It reinforced the importance of the heath and safety of patients attending hospital and in particular the safe storage of dangerous drugs.
"Now this case has concluded, I am hoping my young son and I can have some closure and put this terrible tragedy behind us."
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