PFD report

Peter Clive HIGSON · Prevention of Future Deaths report

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Issued 24 Oct 2013•Surrey

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
3

Named on the report

Responses found
2

Of 3 recipients

Stated actions
5

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised1

  1. Potential contraindication of platelet transfusion following stem cell transplant
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. Action

    Undertake an international randomised study with NHS hospitals and other organisations investigating the benefits and risks of prophylactic platelet transfusion.

    Stated by NHS Blood and TransplantStated completedThe respondent said that this action was complete when they made their response on 18 December 2013.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    Prophylactic platelet transfusion was appropriate, and respiratory deterioration was likely caused by factors other than the transfusion.

    Stated by Department of Health and Social CareDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Potential contraindication of platelet transfusion following stem cell transplant

Wider context from the report

“The platelet transfusion (12 & 13th March 2013) following the stem cell transplant (28th January 2013, seemed to have a major detrimental effect on the deceased and features, if only chronologically, in the ultimate chain of causation leading to his death. A question arises as to whether there was any aspect of e.g., the stem cell transplant interacting with the platelet transfusion suggesting that on occasions such transfusion might be contra-indicated. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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

Undertake an international randomised study with NHS hospitals and other organisations investigating the benefits and risks of prophylactic platelet transfusion.

Verbatim wording from the response

“NHSBT has recently specifically undertaken an international randomised study with NHS hospitals and other organisations investigating the benefits and risks of prophylactic platelet transfusion. Most of the patients in the study had received”

Source location

2013-0277-Response-by-NHS-Blood-and-Transplant
Page 2 · response
Published 18 December 2013

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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

Prophylactic platelet transfusion was appropriate, and respiratory deterioration was likely caused by factors other than the transfusion.

Verbatim wording from the response

“NHSBT provided a report on the circumstances leading up to the death of Mr Higson, together with information on the measures in place to minimise the risk of an adverse outcome to a platelet transfusion. On the basis of this, it appears that prophylactic platelet transfusion was an appropriate treatment for Mr Higson, and that the respiratory deterioration leading up to his death is likely to have resulted from causes other than the transfusion.”

Source location

2013-0277-Response-by-Department-of-Health
Page 1 · response
Published 18 December 2013

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

Platelet transfusion is not considered contraindicated in similar patients, so no action is considered necessary to prevent future deaths.

Verbatim wording from the response

“Given these points, it does not appear that platelet transfusion would be contra-indicated for patients in Mr Higson’s situation, or that action is required to prevent future deaths in similar circumstances.”

Source location

2013-0277-Response-by-Department-of-Health
Page 2 · response
Published 18 December 2013

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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

Current evidence and guidelines support platelet transfusion after chemotherapy and stem cell transplantation because bleeding risks outweigh transfusion risks.

Verbatim wording from the response

“The Coroner explicitly questioned whether the stem cell transplant or other factors may be a contraindication to platelet transfusion. National guidelines supported by randomised studies have suggested that the risk of adverse effects of transfusion (including TRALI) are outweighed by the benefits of reducing the risk of bleeding in patients with low platelet counts following chemotherapy and stem cell transplantation (BCSH 2003).”

Source location

2013-0277-Response-by-NHS-Blood-and-Transplant
Page 2 · response
Published 18 December 2013

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.4

  1. 1

    Maintain TRALI prevention measures at least as stringent as those of international peers while preserving blood-component availability.

    Stated by NHS Blood and TransplantStated completedThe respondent said that this action was complete when they made their response on 18 December 2013.
  2. 2

    Participate with haemovigilance organisations in recording adverse events and identifying potential additional interventions to prevent recurrence.

    Stated by NHS Blood and TransplantStatus unclearThe respondent did not make the status of this action clear when they made their response on 18 December 2013.
  3. 3

    Screen all female apheresis platelet donors for leucocyte antibodies to reduce TRALI risk.

    Stated by NHS Blood and TransplantStated completedThe respondent said that this action was complete when they made their response on 18 December 2013.
  4. 4

    Operate a designated NHSBT expert notification process for suspected TRALI cases, using clinical details and implicated donation numbers.

    Stated by NHS Blood and TransplantStated completedThe respondent said that this action was complete when they made their response on 18 December 2013.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2

  1. 1

    The deterioration was unlikely to be TRALI because its timing and absence of donor WBC antibodies indicated other causes of lung injury.

    Stated by NHS Blood and TransplantDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
  2. 2

    Existing TRALI prevention measures are at least as stringent as international peers and have reduced TRALI incidence.

    Stated by NHS Blood and TransplantExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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

Maintain TRALI prevention measures at least as stringent as those of international peers while preserving blood-component availability.

Verbatim wording from the response

“2.2 Potential future preventative action: NHSBT has undertaken measures at least as stringent as international peers to reduce the risk of TRALI whilst ensuring that blood components are available for patients who need them. These measures have been successful in reducing the incidence of TRALI and are detailed in the appendix. Acute lung injury and acute / adult respiratory distress syndrome (ARDS) can be caused by other disorders such as a chest infection in the absence of transfusion.”

Source location

2013-0277-Response-by-NHS-Blood-and-Transplant
Page 2 · response
Published 18 December 2013

Open published response

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

Participate with haemovigilance organisations in recording adverse events and identifying potential additional interventions to prevent recurrence.

Verbatim wording from the response

“As the respiratory deterioration occurred more than 6 hours after the transfusion, the deceased in this case had other reasons for ALI / ARDS and as the female donor had no WBC antibodies the SHOT imputability criteria would suggest that TRALI was unlikely. Recent studies and current guidelines suggest that the benefits of platelet transfusion in preventing bleeding following chemotherapy and stem cell transplantation outweigh the risk of transfusions themselves. NHSBT undertakes measures to reduce the risk of TRALI that are at least as stringent as international peers. The MHRA and the SHOT haemovigilence scheme record adverse events including respiratory deterioration and, in conjunction with NHSBT and other organisations, identify potential additional interventions to prevent recurrence.”

Source location

2013-0277-Response-by-NHS-Blood-and-Transplant
Page 3 · response
Published 18 December 2013

Open published response

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

Screen all female apheresis platelet donors for leucocyte antibodies to reduce TRALI risk.

Verbatim wording from the response

“NHSBT records showed that the index apheresis platelet unit G0525 1335 7413 A was collected from a male apheresis donor (53 donations, 44 platelet donations). Donation G0525 1334 7540 S was collected from a female donor (35 donations, 9 platelet donations). As part of the TRALI preventive programme all female apheresis platelet donors are screened for leucocyte (white blood cell - WBC) antibodies. This female donor has been screened for leucocyte antibodies (white cell antibodies which can cause TRALI) and none were identified.”

Source location

2013-0277-Response-by-NHS-Blood-and-Transplant
Page 2 · response
Published 18 December 2013

Open published response

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

Operate a designated NHSBT expert notification process for suspected TRALI cases, using clinical details and implicated donation numbers.

Verbatim wording from the response

“2.1 Immediate Corrective Action: For suspected TRALI cases, hospital clinicians contact NHS Blood and Transplant (NHSBT) and provide the clinical details and donation numbers potentially implicated to a designated TRALI expert within NHSBT (Dr ████████ for London and South East Region). As the Coroner’s report was the first notification NHSBT had received of this matter, Dr ████████ contacted both ████████ (Lead Transfusion Practitioner) and Professor ████████ (Consultant Haematologist) at Frimley Park Hospital. Ms ████████ and Prof ████████ reviewed the case notes.”

Source location

2013-0277-Response-by-NHS-Blood-and-Transplant
Page 1 · response
Published 18 December 2013

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 deterioration was unlikely to be TRALI because its timing and absence of donor WBC antibodies indicated other causes of lung injury.

Verbatim wording from the response

“As the respiratory deterioration occurred more than 6 hours after the transfusion, the deceased in this case had other reasons for ALI / ARDS and as the female donor had no WBC antibodies the SHOT imputability criteria would suggest that TRALI was unlikely. Recent studies and current guidelines suggest that the benefits of platelet transfusion in preventing bleeding following chemotherapy and stem cell transplantation outweigh the risk of transfusions themselves. NHSBT undertakes measures to reduce the risk of TRALI that are at least as stringent as international peers. The MHRA and the SHOT haemovigilence scheme record adverse events including respiratory deterioration and, in conjunction with NHSBT and other organisations, identify potential additional interventions to prevent recurrence.”

Source location

2013-0277-Response-by-NHS-Blood-and-Transplant
Page 3 · response
Published 18 December 2013

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

Existing TRALI prevention measures are at least as stringent as international peers and have reduced TRALI incidence.

Verbatim wording from the response

“2.2 Potential future preventative action: NHSBT has undertaken measures at least as stringent as international peers to reduce the risk of TRALI whilst ensuring that blood components are available for patients who need them. These measures have been successful in reducing the incidence of TRALI and are detailed in the appendix. Acute lung injury and acute / adult respiratory distress syndrome (ARDS) can be caused by other disorders such as a chest infection in the absence of transfusion.”

Source location

2013-0277-Response-by-NHS-Blood-and-Transplant
Page 2 · response
Published 18 December 2013

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026