CHANGES MADE AFTER BLUNDER.
A MEDICAL blunder has led to major changes being made at a Teesside hospital - after a pensioner was given the wrong blood during emergency surgery.
An inquest into the death of Ronald Havelock, from Eston, ruled that the shocking mix-up at James Cook University Hospital in Middlesbrough did not contribute to the 69-year-old's death.
But health chiefs today apologised to his family and confirmed that changes have since been made to prevent such an incident from happening again.
Director of nursing at South Tees Hospitals NHS Trust Tricia Hart said: "We know this has been a very distressing and upsetting time for the family and everyone concerned, and we are sorry.
"Staff involved in Mr Havelock's care were extremely upset and saddened by his death. A full internal investigation was carried out by the trust at the time and we have already made changes in practice around the transfusion of blood."
Mr Havelock was undergoing emergency surgery for a ruptured aneurysm in December 2004 when he was given two units of the wrong blood type.
Teesside Coroner Michael Sheffield accepted that mistakes had been made, but said it would be 'quite inappropriate' to suggest that neglect contributed to Mr Havelock's death.
Mr Sheffield ruled that the effects of the mis-match were minimal and chose to record a verdict of death by natural causes.
The family today spoke of their relief that the inquest is now over and said that though they hope to move forward, they will never forget Ronald - a much loved husband, father and grandfather.
Their solicitor Jonathan Fletcher said: "The family were pleased to hear evidence during the inquest that procedures for the checking of blood prior to transfusion into a patient have been changed by James Cook University Hospital to ensure that such a mistake does not happen again and that no other family has to go through the anguish that they have over the last three years."
Changes in practice at the trust since the mix-up include:
Blood transfusion competency training is now given to all health workers involved in any part of the blood transfusion process fromporters to nurses
Training has been enhanced by the National Patient Safety Agency
Any patient who undergoes a procedure that involves loss of consciousness now has two identity badges attached to their wrist and ankle.
If an identity badge has to be removed during a procedure, another badge is attached to another part of the patient's body.
Records show that Mr Havelock, who was blood type O, was given around 600ml of blood type A - due to staff accidentally referring to a previous patient's records.
The inquest heard how a patient given the wrong type of blood would be expected to show a rise in heart rate or a drop in blood pressure, but Mr Havelock exhibited neither of these reactions.
Mr Havelock, a former Evening Gazette worker, had been admitted to hospital on December 19, 2004, for what his family believed to be a fairly routine operation.
But Mr Havelock never regained consciousness and despite undergoing another operation days later to remove part of his colon and gall bladder, he died on Christmas Eve 2004.
Cleveland Police launched a detailed investigation, but it was decided that no criminal charges would be brought against any members of staff involved in the operation.
After a three day inquest at Teesside Coroners' Court, the cause of death was recorded as being due to shock and haemorrhaging, as a result of a ruptured aortic aneurysm, which was brought on by stenosing atherosclerosis and impaired cardiac function.
BLOOD ERROR: Ron Havelock was given the wrong blood in his operation
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|Publication:||Evening Gazette (Middlesbrough, England)|
|Date:||Jul 3, 2008|
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