Coroner's Finding: SQUIRES Dorothy Alberta

90y · Female·incompatible blood transfusion resulting in haemolysis and multi-organ failure complicating an acute myocardial infarction

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.