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Transfusion confusion

14 September 2014

Mrs Y, 38, was admitted to hospital under the care of consultant Dr F for treatment of anaemia due to excessive menstrual bleeding. A sample of her blood was taken for grouping and cross-matching, for the purpose of a blood transfusion; a pack of compatible A-positive donor blood was sent to the ward for this purpose.

After the transfusion began, Mrs Y asked about the blood grouping, telling the nurse that she thought she might be A-negative. The nurse immediately stopped the transfusion and reported this to the laboratory technician – by which time, three to four drops of blood had already been transfused. However, the technician replied that the cross-matching was compatible, and advised that the transfusion should continue while he rechecked the cross-matching.

A short time later, the technician informed the nurse that Mrs Y was in fact A-negative and that the transfusion should stop; by this time, another six to seven drops of blood had been transfused. A blood sample was taken from Mrs Y and she was immediately administered dextrose saline and hydrocortisone intravenously.

Upon clinical examination and observation, Mrs Y’s condition was normal. Both the pre and post-transfusion blood samples had been tested for haemolysis and antigen-antibody reaction (Coomb’s test), and both tests had shown as negative for any reaction. A day later, Mrs Y was referred to a consultant obstetrician and gynaecologist for a full review of her menorrhagia, and a vial of anti-D was administered to Mrs Y. The following day, Mrs Y was discharged from hospital.

Mrs Y attended the hospital two weeks later where her condition was found to have improved – her haemoglobin level had increased, she was feeling less tired and there were no more palpitations. Mrs Y was asked to attend a further follow-up a month later, but did not attend. She made a claim against both Dr F and the hospital for the errors in her blood transfusion, alleging pain and suffering, and emotional stress and psychiatric injury.

Expert opinion

Although there had been a clear breach of duty in the error made during the blood transfusion, the experts for both MPS and Mrs Y disagreed over causation. Although Mrs Y had suffered no adverse reactions as a result of the transfusion, and had been administered with the necessary remedial measures, she alleged psychiatric injury; the experts instructed by Mrs Y’s legal team stated that she was indeed suffering from major depressive disorder with psychosis, as a result of the erroneous transfusion.

The expert instructed by MPS, a consultant psychiatrist, said that the 17-month period between the blood transfusion and the alleged diagnosis of major depressive disorder was rather prolonged for a connection to be drawn between the two incidents.

MPS denied any liability on the part of Dr F in the claim, stating that although he ordered the blood transfusion and had overall responsibility for the care of Mrs Y, he could not be held accountable for the mistake of the hospital’s laboratory technician.

The allegations against Dr F were subsequently dropped and the hospital accepted full liability for the incident and Mrs Y’s psychiatric injury, settling the case for a low sum.

Learning points

  • Being open about errors following an adverse event is important.
  • Listen carefully to the history given by the patient, and don’t hesitate to query a course of treatment even after it has started.
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