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3MG042 Immunology And Transfusion Medicine

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Coroner recommends changes after blood mix-up patient death

The South Australian coroner has recommended carers and relatives be encouraged to accompany heart patients to pre-surgery procedures.
This comes after a 71-year-old patient died when she received a transfusion of the wrong blood type.
 
Prior to her heart surgery Ruth Stoll was required to go to Clinpath Laboratories to give a sample of blood so it could be tested in case she needed a transfusion.
 
She was there with another patient Martha Kovendy.
 
The one nurse in turn took blood from both women but, as the coroner found, she mislabelled the two test tubes.
 
Ms Stoll did require a transfusion during her operation but received the wrong blood. She died six days later.
 
Coroner Wayne Chivell recommended carers should be present at these pre-operative procedures.
 
Ms Stoll's sister-in-law and Ms Kovendy's husband remained outside in the waiting area while the blood samples were taken.
 
The coroner said heart patients are often very anxious and do not communicate well. The presence of carers would minimise the risk of error or confusion.
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