Daily Insight: Blood and blunders

Transfusion never events uncovered at a troubled trust were just the “tip of an iceberg”, an external review has concluded, after more than 150 further incidents were identified.

The Royal College of Physicians was tasked to investigate seven never events at University Hospitals Birmingham Foundation Trust, involving the wrong blood being administered to patients between 2019 and the start of 2023. 

Throughout the course of their investigation, two further events occurred and reviewers found one patient had received incorrect blood transfusions six times, bringing the total number of never events to 14.

The college said in a resulting report, obtained by HSJ, that it was unlikely the reviewed never events “comprised the totality” of transfusion errors at the service.

It cited minutes of the hospital transfusion group meeting from September 2023, which detailed 156 “adverse events” occurring at the service between May and July 2023.

These included a woman being incorrectly transfused with group O RhD positive blood, risking her antibodies attacking a future unborn baby. 

The report concluded there had been “inaction” at senior management level on addressing the problems and a lack of understanding among senior leaders about the significance of the risks posed by the service.

Dreaming Spire

A trust that recently bought a small private hospital is to take on 2,500 long-waiters from across its integrated care system.

Maidstone and Tunbridge Wells Trust is using the extra capacity offered by its £10m purchase of the Spire Hospital in Fordcombe to address long waits faced by patients in Kent and Medway ICS.

In April, one in eight people in Kent and Medway were on a consultant-led referral to treatment waiting list, with nearly 3,000 waiting more than 65 weeks and 579 more than 78 weeks.

The plan is for 2,500 long-waiters to be referred to the trust and receive treatment by the end of the financial year, with many having an initial outpatient appointment within a week.

The first 400 patients are in gastroenterology, pain management, ENT, trauma, and orthopaedics. Patients may be treated at Fordcombe or other trust sites.

MTWT chief executive Miles Scott said: “The extra capacity the site enables us to provide across our hospitals will support the NHS across Kent and Medway.”