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A PENSIONER was given the wrong type of blood during an emergency operation at a Teesside hospital and later died, an inquest heard.

Ronald Havelock, 69, from Eston, had suffered a burst aneurysm and was undergoing surgery at James Cook University Hospital, in Middlesbrough, when medical staff noticed there had been an error with the transfusion process.

Records show that Mr Havelock was given two units of the wrong blood - the equivalent of around 600ml.

Mr Havelock never regained consciousness and, after undergoing another operation days later to remove part of his colon and his gall bladder, he died on Christmas Eve 2004.

Teesside Coroner Michael Sheffield had previously referred the case to Cleveland Police to see whether charges of manslaughter should be brought, but the Crown Prosecution Service decided not to pursue any charges.

Registrar in anaesthesia Benjamin Norman was the first to notice that there had been a mismatch during the transfusion.

Mr Norman told the inquest: "I noticed that the transfusion records related to the previous patient who had received emergency surgery earlier that night.

"The blood being transfused was checked and noted to be of the wrong type, so the transfusion was stopped."

According to Mr Norman, different hospitals have different procedures when labelling bags of blood, but in this case the bags were labelled with the blood type, rather than Mr Havelock's details.

The former Evening Gazette worker had been admitted to hospital on December 19, 2004, for what his family believed to be a fairly routine operation.

His son, Colin Havelock, from North Ormesby, spoke of his shock when he was first told about the mix-up.

Mr Havelock said: "The doctor said it was their fault and couldn't explain what had happened. He couldn't apologise enough and, by the look on the faces of the medical staff, I knew it was very serious.

"I couldn't believe what I was hearing or what they were saying. I asked what it meant and I was told it was not an ideal situation, but they were going to try and rectify it."

The court was told that the mix-up occurred when staff at the hospital failed to check the blood's compatibility slip against the patient's wristband or notes during the emergency transfusion.

Anaesthetist nurse Eleanor Williamson, who collected the blood from the theatre fridge, said: "We normally would take the patient's notes or a label from the notes to the fridge but on this occasion I omitted to do that."

The inquest heard how she checked the blood against its compatibility slip with healthcare assistant Rickman Betts to ensure the blood bank had sent the right units but failed to check they were giving them to the right patient.

Ms Williamson said there was a degree of urgency and they had been working from 8.45pm to 5am without a break.

She added: "The patient's wristband had been removed to aid the insertion of an arterial line."

Mr Betts said: "It had not registered with me that the name on the units was not the same as the patient on the table."

Specialist registrar Dr Ian Whitehead said he had asked whether the blood had been checked before it was given to the patient and he was told it had been.

Consultant anaesthetist Dr Simon Baker, who led the team, said the correct blood was infused about 10 minutes later.

He said the matter had been investigated and recommendations had been made to prevent a repeat occurrence.

Hospital staff claim the effects of the blood mix-up were minimal and say that Mr Havelock died as a result of his ruptured aneurysm, which leaves patients with a 50% chance of survival.

Consultant vascular surgeon Christopher Wood, who carried out Mr Havelock's surgery, said: "When you have a patient who is already at death's door with a ruptured aneurysm, you know he's got a toss of a coin's chance of survival.

"Anything else is obviously going to be a cause for concern whether it may only tip the balance by as little as 1%. But there was no evidence that it affected this at all. I never once thought 'Oh, what's happened here?"

The inquest heard how a patient given the wrong type of blood would typically show a rise in heart rate or a drop in blood pressure, but neither were exhibited in the case of Mr Havelock.



ERROR: Ronald Havelock, 69, was given the wrong blood type during an emergency operation at James Cook University Hospital and later died; TRAGIC DEATH: Ronald, right, with awards given for his swimming successes over a period of 53 years. He is pictured above with son Colin
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Publication:Evening Gazette (Middlesbrough, England)
Date:Jul 1, 2008
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