Thursday, February 02, 2006

Manslaughter charged following wrong blood fatality in UK

Updated 9 Nov. 2013
There have been only a few court cases involving medical laboratory technologists/scientists but there is currently one happening in the UK:
Biomedical scientist on trial in the UK for gross negligence manslaughter

The case involves a group O patient who was mistyped as AB, received group A red cells, and died from multi-organ failure, presumably secondary to a severe hemolytic transfuion reaction caused by multiple errors. Not only was the patient mistyped, but she was apparently crossmatched with outdated gel cards. An in-house protocol to have a second person verify the results at the blood grouping stage was not followed. And a second person was also mistyped as group AB, fortunately not requiring transfusion.

The defendant has admitted his mistakes, claimed "mental aberration", and argued that there were contributing deficiencies at the hospital which had nothing to do with him, such as staff shortages, and that the transfusion had been unnecessary.

Anyone who has performed ABO blood typing knows that mistyping a group O person as group AB means that the grouping was read "bassackwards". In a way it's like reading the number 2006 as 6002. Regardless, it's a relatively common error made by newbee students but an incredible error for an experienced technologist to make.

Breaking in-house protocols designed to increase safety, such as requiring a second person to verify ABO blood grouping, is unacceptable but does happen, particularly under the stress of urgent calls for blood. In this case ignoring the protocol appears to be a systemic error, since the lab was cited for it during an earlier audit.

Using outdated reagents such as the gel cards used for antibody screening and crossmatching is another major error. The newspaper report of the court case suggests that the laboratory may have been trying to save money by using outdated cards that it had in excess quantity due to poor inventory management. Even if quality control of the outdated reagents was acceptable, using outdated reagents for something as critical as antibody detection and compatibility testing breaks regulatory blood safety standards.

My experience with using outdated reagents in the student lab shows that most reagents work well past their expiry date. And many transfusion services use outdated reagents under special circumstances, e.g., use rare reagent antisera for antigen phenotyping; use outdated rare red cells as positive controls for antigen phenotyping.

It would be interesting to investigate if outdated gel cards function acceptably past their shelf life and for how, even if they cannot be used for patient testing, since this may indicate another technical error by the accused in this case. Regardless of any suspending media and reagents, the crossmatch gel cards would have contained patient group O plasma and donor group A red cells.

In summary, from a regulatory perspective, this case involves multiple errors:

  • technical (human) error in misinterpreting the ABO blood group
  • failure to follow SOPs (no second person verified the ABO blood)
  • failure to use in-date reagents (gel cards)
  • possible technical (human) error in not detecting the ABO incompatible donor units in the crossmatch.
Some of the errors seem system-wide but others seem specific to the individual's actions. All of which serves to illustrate that you cannot entirely prevent human error. But much progress can be made and efforts continue. See, for example:
More details of manslaughter case:
What's New on TraQ


3 comments:

  1. Anonymous8:51 AM

    One of the many things that troubles me about this UK case, is a fact of life in Transfusion labs. That is, Transfusion technologists work alone a great deal of the time. Evening and night shifts are generally covered by one technologist; in large centres they are only responsible for Transfusion, in small centres they cover multiple responsibilities. In both settings they are required therefore to double check their own serological results. Whereas this doesn't often lead to catastrophes like the UK case, the danger is there.

    ReplyDelete
  2. Very helpful to have found this (7 years after you posted), thanks.

    ReplyDelete
    Replies
    1. Thanks, Paul. Note that I updated the links on this blog and the one following about the case collapsing.

      Delete

Note: Only a member of this blog may post a comment.