Death following wrong blood transfusion - hospital’s role

Mulago hospital, Uganda’s national referral hospital, was sued for negligence when a mother died in its Intensive Care Unit shortly after a surgical operation. During the operation the mother was transfused with blood she should never have been given. The particulars of the negligence were that the hospital failed to:
•Have in place an efficient communication system within the hospital to handle emergencies and this led to the mother’s death.
•Hire and motivate sufficient staff at the hospital to diligently handle all patients.
•Keep proper records of patients at the hospital for easy access in the event of urgent need for reference to these records.
•Ensure that there are enough drugs, blood and other medical requirements at all times in the hospital for use when emergencies arise.

•Ensure that there is basic functional equipment available in the hospital.
The mother had delivered all her previous three children in the hospital. This was her fourth delivery. She had also attended part of her antenatal services in the hospital. And so when she started bleeding profusely and abnormally during her fourth pregnancy, she opted to come to Mulago hospital. The doctor who attended to her noted that the bleeding was too much that it was no longer safe to continue to wait for the baby to reach maturity. A decision was therefore taken to deliver the baby through a caesarean section. And as is the case in such emergency operations, some blood was taken from the mother to determine her blood group and also cross-match it with compatible blood in readiness for blood transfusion should the need arise.

Danger sign
The operation started at 6.30pm and ended at 10.30pm and during all this time there was no member of staff in the blood bank to deal with this emergency. Court noted with concern that the absence of staff at the blood bank for the period the deceased was being operated on and their failure to respond to requests for blood was symptomatic of an administrative lapse and a system’s failure on part of the hospital administration. It therefore noted that it amounted to gross negligence and breach of the duty that the hospital owes, generally, to its patients, that included the deceased.

Court also observed that a blood bank of any hospital ought to be fully stocked with all types of blood groups and frozen blood plasma for transfusion as and when such is required. Court heard that the mother was transfused with one unit of the correct blood at about 1am which was seven hours after the deceased had experienced massive bleeding. A professor who works in the hospital and led the team that carried out the internal audit into the mother’s death testified in this case, told court that the surgeon had tried to call the blood bank but the call could not go through. To the team there was insufficient human resource in the hospital to handle this particular emergency.

The professor and her team also observed that at that time there was no blood at the blood bank which was crucial since the mother needed blood. The team also concluded that such a situation jeopardises lives of patients.
A haematologist told court that generally there is shortage of blood in the country especially as the country depends on voluntary non-remunerated donors and that the demand for blood far outweighs the current supply.
The haematologist also told court that Mulago hospital does not have a provision for onsite blood donation for those willing to donate blood such as family members in case of emergencies.

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To be continued