Patients given wrong blood at Birmingham hospitals during bone marrow transplants

Several people were given incompatible blood types in Birmingham since April 2020, it has been revealed.

Patients at Queen Elizabeth (QE) and Heartlands hospitals were victim to the mix ups which are partly due to ineffective record keeping.

These incidents are part of 16 such mistakes made in England in the same two year period. In the NHS, these incidents come under a category called "never events" because they are so serious they should never happen.

University Hospitals Birmingham Foundation Trust (UHB), under which the QE and Heartlands sit, has recorded 18 "never events" in total since April 2021, which is significantly high compared to other trusts in the country.

UHB governors discussed the issue at their bimonthly meeting last Thursday.

The mistaken blood types are typically being given to bone marrow transplant patients. Their new marrow require blood matching the donor's type and not the type of the person receiving the transplant.

However, the system for recording this information only allows for one blood type to be recorded.

Birmingham's Queen Elizabeth Hospital. Credit: PA

Chief Medical Officer Simon Ball said: "Every never event is a serious incident which gets thoroughly investigated, but clearly we have got a theme regarding incompatible blood transfusions.

"There is a procurement exercise for a new laboratory information management system that will allow us to deal with this and provide computerised support for that decision making process.

"At the moment it relies on laboratory scientists checking a written record; it doesn't allow for two blood groups to be present.

"I suspect once you correct and take out the bone marrow transplant group, then we wouldn't be an outlier.

"So it partly reflects the bone marrow transplant practice we've got and it's probably worth saying that that is a particularly low risk group in terms of blood grouping compatibility."

A UHB spokesperson said: "Following the CQC's most recent inspection in June 2021, cancer services were rated 'good', with a number of outstanding areas of practice highlighted, including in haematology.

"UHB is one of the highest users of blood in England, with nearly 50,000 units being used in the last 12 months. As a learning organisation, we always take a very open and transparent approach when reporting any clinical incident; the incidents that have been reported since 2020 caused no harm to patients.

"All of our transfusion laboratories are fully accredited to the UK Accreditation Service (UKAS), with the most recent inspections taking place in November 2021 and March 2022.

"Compliance reports are also submitted annually to the Medicines and Healthcare Regulatory Authority (MHRA).

"Staff involved in the blood transfusion process all undertake specific training for this role and undergo regular assessments of competency."