Woman’s Death Caused By Incompatible Blood

Press, Volume CI, Issue 29778, 22 March 1962, Page 12

Woman’s Death Caused By Incompatible Blood

The substitution of one patient’s blood for that of another when groupings and cross-matchings were being carried out by a woman laboratory technologist resulted in an incompatible blood transfusion being given at Calvary Hospital on December 22 to a married woman, and this caused her death, according to evidence given in the Coroner’s Court when the inquest into the woman’s death was concluded yesterday.

The Coroner (Mr A. T. Bell) found Margaret Burt died at Calvary Hospital on December 22, the cause of death being peripheral circulatory failure attributable to an incompatible blood transfusion.

Detective Chief Inspector M. Brown represented the police, and Mr C. M. Roper appeared for the relatives of Mrs Burt and Mr A. D. Holland for Dr. T. W. Milliken. Thomas William Milliken, a plastic surgeon and a Fellow of the Royal College of Surgeons, said that at 8 p.m. on December 16 he was asked by Dr. David Orchard to see Mrs Burt, who had been burned about the neck and chest when she was preparing an evening meal. Five per cent, of her body area had been burned. He considered that the burns had destroyed all the skin ii the area, and that the dead skin would require removal by operation and replacement with skin grafts. Mrs Burt’s condition was satisfactory, and he arranged for her immediate transfer to Calvary Hospital. She was shocked for about 48 hours after the accident, but the burns were not a danger to her life. “On December 21 I decided that arrangements could be made to excise the dead skin in the neck and chest, and I asked Dr. Colin Pearson to take blood from her to determine if she was anaemic and to have her blood typed at the Christchurch Public Hospital blood bank,” the witness said. Arrangements were made for two pints of blood for Mrs Burtt to be sent to the operating theatre for 11 a.m. on December 22. Dr. Pryor administered the anaesthetic, and Mr W. O. S. Phillipps assisted with the operation “The operation commenced as planned, and I excised the skin on the neck and chest and covered this area with skin grafts, from her right thigh,” the witness said. “Operations of this nature, where large areas of skin are excised, are accompanied by a considerable degree of shock. It is the practice to administer blood transfusions during the operation. Labels Checked

“Dr. Pryor and I checked that the labels on the bottles of blood Indicated that the blood was for Mrs Burt, and the transfusion was ommenced by Dr. Pryor.” The witness said that the operation went very well, and he enclosed the neck and shoulders in a plaster-of-paris cast at the end of the operation. The first pint of blood and part of the second were given while the operation was in progress. “Mrs Burt reacted normally under the anaesthetic, but tovzards the end of the operation Dr. Pryor and I discussed whether a third pint of blood would be of benefit to her. We agreed to give her a third pint, and duly ordered it from the Christchurch Hospital. “No unusual reaction to the operation, the anaesthetic, or the blood transfusion appeared, except that the patient seemed to be slightly more shocked than we expected," the witness said “This caused no alarm, be. cause the amount of shock with an operation varies from patient to patient. She was returned to her bed about 1 p.m. I was not concerned about her condition, and advised her husband accordingly soon afterwards. The blood transfusion was continued.

"At 2 p.m. I received a message that the blood trans, fusion should be stopped, as the blood bank feared that Incorrect blood had been sent I saw the patient at 2.10 p.m, and by this time she had become shocked. I instituted anti-shock treatment, and spoke to Dr. Gunz, of the blood bank, who said he would come to the hospital immediately with the right blood In the meantime I arranged for a plasma substitute of the correct blood to be administered immediately until the correct blood arrived.

"The patient had had two pints of incompatible blood when the transfusion was stopped.” the witness said “She was given the correct blood and cortisone to overcome the shock. This was the only treatment which could be given to assist her recovery. Although she responded for two hours, at, 4.45 p.m. she became ex-

tremely shocked, and she died after 5 pun.” Anaesthetist’s Evidence William James Pryor said that half an hour after the operation commenced it was decided that a transfusion was necessary and the blood was sent for. Sister Malcolm received it in the theatre, and checked the patient’s name on the packing slip, the surgeon’s name, the blood type, and the serial number on the bottle with the ticket on the bottle and the number affixed to the bottle itself. The blood was labelled, “Group A Rh positive, for Margaret Burt, Surgeon Mr Milliken, Nos. 6316 and 6294.” “The particulars were first checked by Sister Immaculate with Sister Malcolm, and then rechecked by myself with Sister Malcolm before the blood was administered.” said the witness.

Frederick Walter Gunz, a hematologist with the North Canterbury Hospital Board, said that a sample of blood was supplied at the blood bank from Dr. Pearson’s laboratory with a request from Mr Milliken for two pints of blood for the morning of December 22. The blood was grouped and crossmatched by Miss E. A. Slee on the morning of December 22. Two bottles were issued to Calvary Hospital soon after

11 p.m. “At 12.30 p.m. the sister from Calvary Hospital rang to order two more bottles of Wood for Mrs Burt,” said the witness. “The cross-matching in this instance was commenced by Miss J. Kelman and completed by Miss Slee, who discovered that the two bottles of blood forwarded to Calvary for Mrs Burt were incompatible. “Wrongly Determined** "On checking It was discovered that Mrs Burt’s blood group had been erroneously determined, and it was group O and not group A.” the witness said. Miss Slee’s report on the laboratory procedures used in grouping Mrs Burt’s blood was clear, and he was satisfied that the usual procedures were observed, including all the many safeguards for the prevention of errors. “Nevertheless, Mrs Burt’s blood was erroneously grouped." the witness said. •“There is no direct evidence to explain this, but circumstantial evidence makes it practically certain that the original grouping's and crossmatchings were carried out not on Mrs Burt’s blood but on that of another patient of Mr Milliken."

After explaining the procedure that had been used for grouping, the witness said it appeared inconceivable that even a junior technician could have misinterpreted the reactions.

"It must be concluded that they did not occur because both the initial groupings and

cross-matehings were not done with Mrs Burt’s blood,” the witness said. “Miss Slee’s account shows that the tests on both patients were done at the same time, and that the tubes used were in proximity to each other. “If accepted, this postulated explanation shows that an error of quite an elementary nature was committed, namely, the substitution of one patient’s blood for another, in the course of testing.” the witness said. The whole routine of blood bank work was designed to prevent exactly that type of accident, he said, and trainees were impressed with its importance and seriousness from the first day they joined the department. "Miss Slee is in her fifth year of laboratory work, and has had considerable experience in the blood bank.” the witness said. “She has so far shown herself capable and reliable, and has had excellent reports from her supervisors. “Lapse Of Attention”

“Her error did not arise from any breach of laboratory routine, but can only be attributed to a complete lapse of attention. Such lapses tend to occur at times of stress, and it is probable that tiredness was the cause in Miss Slee’s case. Possible causes of tiredness were rush of work before the holidays and hot weather.” It had been stated that transfusion accidents could never be completely prevented as long as human beings were involved in laboratory work, the witness said. However adequate the safeguards. they would eventually break down as a result of human failure.

Some years ago one death in every 1000 transfusions was accepted as the average risk. A recent figure from a large New York hospital showed one death from incompatibility in every 11.625 transfusions.

“The present case is the first death attributable to incompatibility which we know to have occurred in Christchurch since 1956.” said the witness. “In this period more than 56.000 bottles of blood have been given, and at the rate of 2.5 bottles a transfusion. the death-rate is one in 22.500 transfusions “Further precautions will be introduced as a result of this regrettable accident, but it is most unlikely that even these will ever make transfusions completely safe.” the witness said.

Elizabeth Anne Slee, a medical laboratory technologist under training in the pathology department of the Christchurch Hospital, said she was in her fifth and final year of training. After completing her final examinations in August she would be a qualified laboratory technologist. She then gave technical evidence of the blood grouping and cross-matching she had carried out.