‘Medical misadventure’ cause of patient’s death

Press, 7 April 1987, Page 5

‘Medical misadventure’ cause of patient’s death

PA Auckland A heart patient died after hospital staff gave him the wrong blood during emergency surgery, the Coroner’s Court at Auckland was told. The Coroner, Mr Stephen Osborne, found that John Crossman Wills, aged 76, died as a result of medical misadventure. He said it was a decision he had rarely made in 30 years as Coroner.

Mr Wills was admitted to Green Lane Hospital in November for an aortic valve replacement by the surgeon, Sir Brian Bar-ratt-Boyes, Sergeant Les Green said.

The patient was later taken to surgery for an emergency by-pass after he began haemorrhaging. Staff used a heart-lung machine prepared for another patient, presuming the attached details be-

longed to Mr Wills. A hospital perfusionist, Timothy Wilcox, said the wrong blood would not have directly caused Mr Wills’ death.

“As the patient was already haemorrhaging it would be very difficult to assess the result of the transfusion with the patient’s death,” Mr Wilcox said. The Coroner said it was very rare that an inquest found death by medical misadventure. “In 30 years as Coroner this is the first case I have come across where there is a connection with the death and incompatible blood,” he said. He found that Mr Wills died during heart-replace-ment surgery complicated by bleeding and accidental transfusion of an incompatible blood. The Coroner noted that

Mr Wills, a war veteran, was frail and desperately ill. Sir Brian Barratt-Boyes said later that Green Lane Hospital blood transfusion procedures had been changed. The hospital now required the patient’s blood transfusion sheets to be checked against his identification bracelet before it could be initialled, and it limited the number of patient labels. No labels would be put on the heart-lung machine. This eliminated the possibility of spare forms being used for other patients. Sir Brian said that he supported the change.

“The incompatible blood would not have directly caused the patient’s death, but the method obviously needed correction,” he said.