Coroner's Finding: STOLL Ruth Sophie

71y · Female·massive acute haemolysis leading to severe anaemia and multi-system failure as a result of an incompatible blood transfusion

Ruth Stoll, 71, died from massive acute haemolysis and multi-system failure after receiving incompatible blood transfusions during aortic aneurysm repair. Pre-operative blood samples from Stoll and another patient (Kovendy) were inadvertently mislabelled by a registered nurse during collection, resulting in Stoll receiving Group A blood when she was actually Group O. The nurse failed to follow the established Nurse Procedure Manual requiring patients to spell their names—a safeguard that would have prevented the mix-up. Post-operative clinicians could not have detected this error even if casenotes were available. Key lessons: strict adherence to patient identification protocols during specimen collection is critical; independent verification at collection time (not just transfusion) is essential; centralised blood group databases and witness involvement of carers during collection could prevent such errors.