Review launched after London NHS Trust gave blood transfusion to wrong patient

A London NHS Trust has apologised after giving a blood transfusion to the wrong patient earlier this year. Imperial College Healthcare NHS Trust (ICHT) confirmed the patient was not harmed after they had incorrectly been transfused O-negative blood.

A spokesperson for the Trust said they have reviewed what went wrong and strengthened their processes. The incident emerged in a report produced ahead of a Board in Common meeting today (April 16) between ICHT, Chelsea and Westminster Hospital NHS Foundation Trust (CWT), The Hillingdon Hospitals NHS Foundation Trust (THH), and London North West University Healthcare NHS Trust (LNW).

The fudged transfusion is listed as one of two ‘never events’ recorded in January 2024 across the four Trusts. The other was a flexible sigmoidoscopy, a test looking inside the lower part of someone’s large bowel, being performed on a patient requiring an Oesophago-gastro duodenoscopy at LNW.

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According to the report, a 'positive patient identification' was not carried out ahead of the ICHT incident. It notes: “An immediate safety alert was released and the PPID policy reviewed to improve clarity. A new safety improvement priority has been agreed to focus on PPID into 2024/25. The patient did not come to harm.”

A spokesperson for the Trust said they apologised to the patient, and immediately issued a safety alert to all relevant staff. "We subsequently reviewed exactly what happened and have now strengthened our processes for ‘positive patient identification’," they added.

The report details how ICHT recorded the most serious incidents among the four Trusts in January this year, with six. It also recorded the highest reporting rate per 1,000 bed days, with 0.21 against CWFT’s 0.04, LNW’s 0.17, and THH’s 0.08.

Commenting on the figures, the spokesperson said: "To help us provide the best possible care, we really encourage patients and staff to tell us about any concerns or safety incidents, no matter how big or small. This helps us identify areas for learning and improvement.

“We regularly publish data on patient safety, and our latest board papers continue to show a high rate of incident reporting together with harm levels well below the national average. We believe this is an indication of the increasingly open culture we are working to embed across our organisation."

ICHT runs five hospitals in Central and West London, namely Charing Cross, Hammersmith, Queen Charlotte's and Chelsea, St Mary's, and The Western Eye.

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