Admin l Wednesday, December 14, 2016
HERTFORDSHIRE, England – A nurse who used the wrong type of blood during a transfusion which killed a patient in her care has been convicted following a trial.
Lea Ledesma, 49 of Stevenage, Hertfordshire was found guilty at Southwark Crown Court on Wednesday, 14 December of unlawfully killing Ali Huseyin, 76, by gross negligence.She will be sentenced on 9 February 2017. Detective Chief Inspector Graeme Gwyn, of the Homicide and Major Crime Command, said:
“This was a difficult and tragic case for all involved. Our sympathies continue to remain with the family of Ali Huseyin and I hope today’s verdict will bring some comfort after what as been an incredibly difficult time for them.”
The court heard how Mr Huseyin had been taken to the intensive care unit at the London Heart Hospital following a heart bypass operation on 6 May 2014. Mr Huseyin’s surgery had been straightforward and without complications, and he had been transferred to the unit to recover. The nurse in charge of his care was Lea Ledesma. During his first evening in intensive care, Ledesma – a senior staff nurse – had carried out a blood transfusion, without incident.
She concluded her shift at around 20:00hrs and came back to work the following morning, 7 May 2014, at 08:30hrs. Overnight, Mr Huseyin was given another blood transfusion as part of his care – again, this was administered without incident.
During the first hour of the shift, some concerns about Mr Huseyin’s health were raised and it became apparent that he was losing fluid through a chest drain that had been fitted following his operation.
He was examined by the doctor that morning who decided another unit of blood should be transfused.
Ledesma was authorised to obtain the blood which was stored in a secure vending style machine, known as a HemoSafe – the blood can only be obtained by using a patient’s unique reference number.
Usually this is done by scanning a barcode which is issued to the patient on arrival and can be obtained by an authorised person from the medical records. However, if those records cannot be accessed, the unique code can be manually entered into the machine to obtain the unit of blood.
On this morning, Ledesma wrote what she thought was the correct code on her hand before going to the machine. However, there was a patient also on the ward with a similar surname and Ledesma had mistakenly obtained his details.
When obtaining the blood there still should have been sufficient checks to prevent the incorrect blood being transfused into Mr Huseyin. On dispensing the blood, a barcode pertaining to the relevant patient was issued. This would have identified the blood as not being suitable for Mr Huseyin.
Ledesma then noticed that the name on the blood bag did not match the details of her patient. She thought that the patient may have another name so continued. Mr Huseyin was conscious at this time and Ledesma asked him to confirm his date of birth which would have confirmed the blood obtained from the machine was not for him.
However, when he stated this information Ledesma was looking at the wristband on his arm instead of the blood. Ledesma then noted the unique patient number did not match and raised this with a senior colleague who advised the transfusion should not be carried out using that blood and Ledesma should check to ensure her patient’s details had been recorded correctly.
Ledesma went to a computer to check the details but did so against the incorrect records. Believing she had the correct blood she proceeded to carry out the transfusion at around 10:40hrs. Mr Huseyin was blood group O while the blood being transfused was blood group AB.
Shortly after the transfusion Mr Huseyin’s condition began to deteriorate and he was rushed away for surgery. It was only an hour later; at around midday that Ledesma confessed that she had administered the wrong blood to Mr Huseyin.
She initially tried to lay blame for the mistake elsewhere, saying she had taken her information from documentation left by her colleague who had looked after Mr Huseyin during the night and it was that nurse who had given the wrong blood. However, checks of the records showed this was a lie.
When further questioned Ledesma also claimed she had checked the details of the blood she had got from the machine and they matched with Mr Huseyin’s records. However, when pressed she admitted to being distracted and flustered by the patient’s worsening condition and may have not checked the details thoroughly.
Mr Huseyin died later that evening. A post-mortem examination concluded the death was caused by the administration of an incompatible unit of blood. The police were called and Ledesma was interviewed, before being summonsed and charged.
