A health trust has been fined £7,000 for giving a 93-year-old woman a fatal transfusion using blood intended for another patient.

Lilian Harrington, of Heathfield, died seven hours after treatment at the Kent and Sussex Hospital in Tunbridge Wells, Kent, in January last year.

Magistrates heard Mrs Harrington was given the wrong blood type after she had undergone surgery for a broken leg.

Mrs Harrington, blood type O positive, was given blood type A positive from a unit of blood intended for another patient with the same surname.

Since her death, the trust has made sweeping changes to its policies and procedures.Simon D'Albertanson, prosecuting for the Health and Safety Executive, criticised the trust for having "a jumble of old and poorly understood" procedures for carrying out blood transfusions.

He said: "The trust should have had in place a safe system of work, and in this case they did not.The trust cannot rely on the expertise of staff in what can be trying circumstances. If the trust's procedures had been up to date, as they should have been, Lilian Harrington may not have died."

The court heard the trust's blood laboratory was located at neighbouring Pembury hospital and that units of blood had to be transported to the Kent and Sussex Hospital for use.

In Mrs Harrington's case, a consultant surgeon requested two units of blood be given to her but, unknown to nurses, no order for the blood was actually made.

A nursing auxiliary was sent to collect the blood, together with two other orders, but failed to find Mrs Harrington's order. He searched for her blood pack and found one marked with the same surname but did not check that all the details, such as the date of birth, blood type and first name, matched those of Mrs Harrington.

The blood was then taken to Mrs Harrington's ward. Nurses on the ward, who did not check the details on the blood pack, could not place a needle in her arm before changing shift.

The next shift also failed to check the crucial details before finally managing to administer the transfusion at 10.30pm on January 14.

Twenty minutes into the procedure, Mrs Harrington began to feel unwell. She died at 6am the following day.

The HSE claimed essential procedural guidelines were poorly set out in a 1990 trust document.The Maidstone and Tunbridge Wells NHS Trust, formerly the Kent and Sussex Weald NHS Trust, admitted breaching Health and Safety at Work regulations.

David Wood, defending the trust, said: "There has been a degree of human error in this case which must be accepted.

"Very considerable strides have been made since January, 1999. The trust has taken the lead in sharing the lessons learned with other hospitals. They have made a virtue from adversity."

Derek Ireland, magistrate at the Tunbridge Wells hearing, said: "It is a great shame it took the death of a lady who survived two world wars before this positive action was taken. This fine does not in any way reflect on the life of this patient."

The trust has now introduced a new 12-page manual on blood transfusions. Medical director James Lewis said: "Our audits have shown that the new system is working effectively and we are confident that such a tragic error will not happen again."

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