Recurring concern

Failure to provide required blood products promptly for transfusion

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First reported 10 Mar 2014•Latest report 14 May 2024

Definition

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.

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.
Reports
4

Distinct published reports

Individual concerns
5

A report can raise multiple concerns

Date range
2014–2024

First to latest report issue date

Stated actions
1

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

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

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Birmingham and Solihull

    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

  2. Brighton and Hove

    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

  3. Essex

    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

  4. Manchester South

    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
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Data last updated 7 September 2026