A tragic oversight by doctors in Tamil Nadu has left fifteen pregnant women dead. The cause of the deaths was determined to be transfusions of blood later deemed to be stale.
The deaths did not happen in a single, isolated incident. Rather, the deaths occurred at three government-run hospitals over a period of four months. The implication of this is that an oversight of this severity is not merely the outcome of a mistake by a single doctor, but a common occurrence.
Senior doctors and officials later conducted maternal audits and inspected blood banks in Dharmapuri, Hosur and Krishnagiri government hospitals. They found transfusing blood had been kept at inappropriate temperatures for elongated periods of time, causing it to become “spoiled”. When transfused, it led to the death of pregnant women and mothers.
“In many cases women had severe complications and side-effects, including fits, minutes after they were transfused blood. The blood volume in some cases was lower than 50ml,” said a senior health official.
A sweeping criminal investigation has been opened up by state health secretary Beela Rajesh. These proceedings are aimed towards three blood bank officers — Dr M Chandrasekar, working with the Government Medical College and Hospital; Dr Narayanaswamy, working with Krishnagiri District Headquarters Hospital; and Dr Sugantha of the Hosur Government Hospital. In addition, more than a dozen staff nurses and lab technicians are also under investigation.
Those implicated would be charged with negligence and could face losing their jobs. For so many individuals across multiple hospitals to be under investigation indicates that the problem is systemic – potentially occurring even more frequently than currently known.
Other such occurrences involving tainted blood transfusions are more well documented. Recent examples such as a pregnant woman — again in Tamil Nadu — being donated HIV-positive blood bring the screening and safety procedures involved in blood donation under question. In this instance the blood bank manager had certified the blood as safe. This again is not an isolated incident: it reflects a much broader issue. IndiaSpend reported that as many as one in every hundred cases of HIV could be the result of faulty blood transfusions.
Simple lapses in judgement such as these can have unimaginable consequences. For fifteen expectant mothers to die in such a short period of time is nothing less than a tragedy. For a host of qualified professionals to be making such lapses in judgement on a regular basis warrants investigation, as the frequency of these events and the number of individuals involved would indicate severe deficiencies in safety protocol.
