Recurring concern

Failure to provide required blood products promptly for transfusion

First to latest report 10 Mar 2014 — 14 May 2024

Reports that mention this concern: 4
Times this concern has been raised: 5
Stated actions linked to this concern: 1

What this concern includes

Includes failures in the end-to-end provision of clinically required blood products for transfusion, including blood and platelets, covering availability, on-site storage, preparation, equipment, access, scheduling and timely delivery to patients.

What is not included

Excludes transfusion reactions, contraindication decisions and clinical treatment after the required blood product has been provided, unless the provision process itself is deficient.
Excludes general blood-bank, laboratory or hospital-capacity failures that are not specifically linked to timely provision of blood products for transfusion.
Excludes failures limited to documenting, prescribing or administering a transfusion when the required blood product was available and provided on time.
Excludes unrelated medication, fluid, tissue or organ supply failures.

Trends

Reports over time

Reports mentioning this concern, over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Southend University Hospital1

Tameside and Glossop Integrated Care NHS Foundation Trust1

University Hospitals Birmingham NHS Foundation Trust1

University Hospitals Sussex NHS Foundation Trust1

Reports and published responses 4 reports

See individual reports that have raised this concern, and the actions taken in response

14 May2024
Birmingham and Solihull
Concerns raised1
1. Delays in obtaining blood products after major haemorrhage protocol activation
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

University Hospitals Birmingham NHS Foundation Trust
Stated actions 1
1. University Hospitals Birmingham NHS Foundation Trust
  Audit compliance with the Major Haemorrhage Blood Protocol across all UHB sites.
Respondent positions 2
1. University Hospitals Birmingham NHS Foundation Trust
  A blood fridge is not being provided because group O blood is nationally scarce and Heartlands is not a Major Trauma Centre.
  Unable to act
1. University Hospitals Birmingham NHS Foundation Trust
  The blood arrived within 15 minutes after major haemorrhage protocol activation, so the relevant delay was in requesting blood and activating the protocol.
  Disputes the concern
AI-generated summary

James Patrick PEARSON · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

James Pearson was struck by a vehicle on 14 June 2023 and later died at a hospice on 22 October 2023 after sustaining traumatic and hypoxic brain injuries, developing pneumonia, and experiencing a prolonged hospital admission. The concerns included undocumented observations, insufficient doctor coverage during his deterioration, and the time needed to obtain blood products; the report also states that an opportunity to provide fluids was missed and that this would probably have prevented his cardiac arrest and subsequent hypoxic brain injury.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Delays in obtaining blood products after major haemorrhage protocol activation
Wider context from the report
“9. I further heard from ████████ that the blood products at Birmingham Heartlands Hospital are not kept in the ED, and are kept some distance away, and could take up to 20 minutes to obtain after the major haemorrhage protocol is activated. Whilst this is unlikely to have affected the outcome for James, due to his sudden deterioration, I am concerned that a delay in obtaining blood products could lead to future deaths. ”
Source location
James Patrick PEARSON · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Audit compliance with the Major Haemorrhage Blood Protocol across all UHB sites.

Verbatim wording from the response
“A review of all incidents involving activation of the MHP within Heartlands Emergency Department since Mr Pearson’s death has been undertaken. This did not demonstrate any incidents regarding delays in receipt of blood once the MHP was activated. A full audit is underway by the Hospital Transfusion Group to review overall compliance to the Major Haemorrhage Blood Protocol across all UHB sites, the outcome of this will be reported to the Trust Transfusion Committee.”

Source location
Response from University Hospitals Birmingham
Page 3 · response
Published 20 May 2024
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
A blood fridge is not being provided because group O blood is nationally scarce and Heartlands is not a Major Trauma Centre.

Verbatim wording from the response
“The recommendation to consider a blood fridge in BHH ED has been discussed in the Hospital Transfusion team. There are significant consequences to putting a fridge in the ED at BHH, not least that group O blood (which is what would need to be in the fridge if it is being used to support immediate transfusion) is in short supply nationally and needs to be used only for those patients that require it. This includes not stocking it in locations where it is unlikely to be used, which includes EDs (such as Heartlands) which are not in Major Trauma Centres.”

Source location
Response from University Hospitals Birmingham
Page 3 · response
Published 20 May 2024
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The blood arrived within 15 minutes after major haemorrhage protocol activation, so the relevant delay was in requesting blood and activating the protocol.

Verbatim wording from the response
“Availability of blood products within the emergency department You heard evidence that it can take up to 20 minutes to obtain blood products within the emergency department following activation of the major haemorrhage protocol. Whilst this delay was unlikely to have affected the outcome for Mr Pearson, you are concerned that delays in blood products being available could result in future deaths.”

Source location
Response from University Hospitals Birmingham
Page 3 · response
Published 20 May 2024
Open published response
14 Feb2019
Brighton and Hove
Concerns raised1
1. Failure to deliver prescribed blood transfusions as scheduled
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Kenneth George Alfred WHITTINGTON · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Kenneth George Alfred Whittington died following an operation, but the supplied text does not provide further circumstances of his death beyond referring to the Record of Inquest. The principal concerns included inadequate instructions and handover about management of his urinary catheter after bladder repair, failure to check a disconnected epidural despite increasing pain, incomplete blood transfusion and discharge documentation, and a delay to the initial operation because no Junior Doctor was present.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to deliver prescribed blood transfusions as scheduled
Wider context from the report
“(5) On the 2nd May Mr Whittington’s haemoglobin was low. Mr. Whittington needed and was written up to receive two units of blood on the 2nd May. In fact he received one unit on the 3rd May. There is absolutely no rationale for what happened or exploration thereof. This is unsatisfactory ”
Source location
Kenneth George Alfred WHITTINGTON · Prevention of Future Deaths report
Page 2 · concerns
Open source report
16 Jul2014
Essex
Concerns raised1
1. Unavailability of a blood fridge on the ward for immediate access to matched blood
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Julie Ann Robertson · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Julie Ann Robertson died on 11 May 2013 from complications following an operation for an elective total abdominal hysterectomy and bilateral salpingo-oophorectomy. The inquest narrative described delays in escalation, obtaining blood and starting surgery, as well as poor record keeping and unclear timings. The report raised concerns that matched blood was not immediately available on the ward and that there was insufficient formal training in record keeping.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Unavailability of a blood fridge on the ward for immediate access to matched blood
Wider context from the report
“1) The possible need for blood had been anticipated as early as 4:40am. If there had been a blood fridge on the ward then the matched blood could have been brought to the ward so that when a transfusion was called for it would have been instantly available on the ward. The blood eventually arrived at 6.55am by which time Mrs Robertson was unfit for surgery. ”
Source location
Julie Ann Robertson · Prevention of Future Deaths report
Page 2 · concerns
Open source report
10 Mar2014
Manchester South
Concerns raised2
1. Unavailability of an agitator for on-site platelet preparation
2. Unavailability of platelets on site for transfusion
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Afifa Qaisar · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Afifa Qaisar was admitted to Tameside General Hospital on 23 June 2013 with collapse and confusion, initially diagnosed as meningitis with sepsis, and died at 20.30 hours the same day. Concerns included uncertainty about whether drugs recorded as given had actually been administered, unavailability of required resuscitation equipment, failure to notify the RMO, delays in platelet and Hb support, an inappropriate response to an apparently non-running saline infusion, and failure to commence fluid balance monitoring or catheterisation.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Unavailability of an agitator for on-site platelet preparation
Wider context from the report
“4. I heard evidence that she required platelets to be transfused but there was a considerable delay in these being made available “because “they are not kept on site”, and in any event there is no ‘agitator’ on site for their preparation. ”
Source location
Afifa Qaisar · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Unavailability of platelets on site for transfusion
Wider context from the report
“4. I heard evidence that she required platelets to be transfused but there was a considerable delay in these being made available “because “they are not kept on site”, and in any event there is no ‘agitator’ on site for their preparation. ”
Source location
Afifa Qaisar · Prevention of Future Deaths report
Page 1 · concerns
Open source report