Coroner's Finding: STOLL Ruth Sophie

Contributing factors

• mislabelling of blood samples during pre-operative collection
• failure to comply with Nurse Procedure Manual requiring patient to spell their name
• absence of double-checking at time of specimen collection
• inadequate patient identification procedures during phlebotomy

Coroner's recommendations

1. Guidelines developed by the Australian New Zealand Society of Blood Transfusions Inc, particularly in relation to blood grouping and cross-matching request forms, should be adopted by all organisations engaged in blood testing
2. A central blood group computer database should be examined further by the Department of Human Services, with potential interstate links and addressing privacy concerns
3. Protocols for blood collection should encourage collectors to have a relative or carer present where possible to reduce the risk of communication difficulties with the patient
4. New request forms for grouping and cross-matching should include specific certification that samples were labelled immediately and proper identification undertaken, with signatures from both collector and witness
5. Double-checking of specimens and patient identification at time of sample collection should be implemented, either by one staff member with the patient or by two staff members