Coroner's Finding: SQUIRES Dorothy Alberta
Deceased
Dorothy Alberta Squires
Demographics
90y, female
Date of death
2003-09-29
Finding date
2005-01-18
Cause of death
incompatible blood transfusion resulting in haemolysis and multi-organ failure complicating an acute myocardial infarction
AI-generated summary
A 90-year-old woman with acute myocardial infarction and cardiogenic shock died after receiving an incompatible blood transfusion (A- instead of O+), which caused haemolysis and multi-organ failure. The registered nurse administering the transfusion failed to complete the bedside identity checking procedure, which requires verification of patient identity in the presence of two nurses before commencing transfusion. Although the patient was critically unwell and unlikely to survive regardless, the incompatible transfusion accelerated her death. The hospital subsequently revised its blood transfusion protocol with clearer procedures including mandatory written patient details at the blood fridge and explicit verbal identity confirmation before administration.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Contributing factors
- failure to complete bedside identity checking procedure
- confusion regarding patient identity after erroneous blood delivery to wrong location
- registered nurse overlooked requirement to check patient identity in presence of two nurses
- incomplete compliance with hospital blood transfusion protocol
- pre-existing critical condition from acute myocardial infarction and cardiogenic shock
Coroner's recommendations
- No formal recommendations made under Section 25(2) of the Coroners Act, as the hospital had already developed and implemented a revised blood transfusion procedure effective 1 March 2004 with clearer and more detailed requirements
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