Labelling mistake contributed to delayed blood transfusion

A labelling mistake by a lab technician contributed to a delay in giving a blood transfusion to a woman who suffered major bleeding after an emergency Caesarean-section, an inquest heard today.

Nora Hyland (31), a Malaysian woman living at Charlotte Quay in Dublin 4, died on the operating table at the National Maternity Hospital (NMH) in Holles Street on February 13, 2012, within three hours of undergoing the procedure to deliver her son Frederick.

The inquest into her death at Dublin Coroner’s Court had previously heard that no emergency supply units of O-negative, the universal blood type, were kept in operating theatres at the NMH at the time.

Dr Nikhil Purandare, then specialist obstetrics registrar at the hospital, said that he made the request for the units at 12.03am after finding that Mrs Hylandhad lost approximately one litre of blood. A docket showed the blood being requested from the lab at 12.13am. The blood was not administered until 12.40am, while Mrs Hyland was undergoing a laparotomy to stop the bleeding with her total blood loss estimated at 3.5 litres following that procedure

At the resumption of the inquest, consultant haematologist Dr Karen Murphy told the court that a laboratory techician made an "administrative" error in labelling the blood requested resulting in a ten minute delay in it being ready for collection from the lab.

The initial request for blood included two units of O-negative immediately in addition to four units in Mrs Hyland’s specific blood type which would take time to prepare. However, a further three units of O-negative were ordered, said Dr Murphy, and the technician made the mistake, which she attributed to “human error”, while preparing the five units in total.

The units were ready for collection at 12.20am but the label referred to a blood sample taken in August 2011 and not the sample taken from Mrs Hyland earlier that evening. When the laboratory technician realised his error, he set about correcting it. Dr Murphy said that regulations prohibited the blood from being sent to theatre with incorrect labelling.

“It is simply a clerical administrative issue,” she said, “More importantly, he would have known that if that blood went up mislabelled and allocated to the 2011 [blood] group, that there may have been confusion in theatre which delayed the transfusion of the blood because it should have been allocated to the current group. It should have had 2012 on it essentially”.

The delay added ten minutes at laboratory level to the overall delivery of the blood, she said. “There was a clerical administration failure. That doesn’t change the clinical issues involved but that explains the delay,” she said.

Mrs Hyland’s husband Stephen and the master of Holles Street, Dr Rhona Mahony, are due to give evidence when the inquest resumes on Monday.