HIV infected blood was transfused to two more babies !

State AIDS Control Society discovers discrepancies Documents manipulated by overwriting Notes of blood transfusion were incomplete

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Bhilai, May 13: Investigating over the second complaint of HIV infected blood transfusion, the AIDS Control Society has found that the infected blood was transfused to two other children also at the JLN Hospital, Sector 9. After interrogating the Raipur based victim parents and doctors as well as staff of BSP’s Jawahar Lal Nehru Hospital and Research Centre, the high level probe committee found negligence in treatment, discrepancies in documentation and irregularities in blood transfusion. The committee found that the infected blood was transfused was two other babies also and directed the authorities to follow-up those cases. The infected blood was transfused to a fourth person also who died after few days.

In its report, the probe committee stated that the reason for HIV transmission to the child is through one of the five blood units (4 units of FFP & 1 unit of PRBC) transfused to the child.

The team reached this conclusion on the basis of Blood donor recall and follow up. The donor was referred to the ICTC where he has been referred to ART Centre Durg for receiving the treatment of HIV Infection. The PRBC (Packed Red Blood Cells) prepared from infected blood units was given two more patients on September 29, 2015 and October 08, 2015. The team stated that the said patients of pediatric age group need to be followed up as they may have contracted the infection. The platelet of the same units was issued on September 21, 2015 to a patient and he expired on September 24, 2015.

Expected attention not paid to precious delivery:  The high level probe committee comprising of experts from the field of Obstetrics & Gynecology; Pediatrics; Microbiology and Blood Bank along with regulatory authorities and deliberated on the process of delivery for exploring the alleged negligence during delivery. The team found that the expected and due attention was not paid to the precious pregnancy by the attending Obstetricians. As the mother was admitted due to leaking, the senior doctors must have given immediate attention and should have taken prompt decision of either to operate or timely intervention so as to avoid complications.

The committee stated that the documents seem to be manipulated by overwriting and the time of delivery of the second baby has documental disparity. The treating doctors claimed to have taken verbal consent but no clear and detailed documents regarding the written informed consent were found in the records. The complainant was not informed by the doctors regarding transfusion to the child.

The probe team was led by Dr Manisha Srivastava (HoD, Blood Transfusion Services, BMHRC, Bhopal). Other members of the team were Dr Vijay Kapse (I/c Model Blood Bank, Medical College Hospital Raipur); Dr Nikita Sherwani and Sanjay Jhadekar (ADC, Food and Drugs Administration, Rajnandgaon).

Recommendations: In view of the seriousness of the matter, the committee recommended Strict Administrative Action and punishment as per law by the authorities after fixing the responsibilities of the Medical and managerial staff of the blood bank and the treating doctors and management of JLN Hospital Sector 9. The committee observed that there has been a transfusion transmitted infection to the victim. The committee further recommended that best treatment help and support through the NACO and the State Health Department; Women and Child Welfare Department and Management of Bhilai Steel Plant should be provided to the child for treatment of infection of HIV at the best centers both in terms of economic, social and psychological rehabilitation of the child and the family. In its last recommendation, the committee stated that the management should realize the seriousness of the matter and steps should be taken for the overall development and quality improvement of the blood bank.

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