Nurse gets suspended sentence over fatal blood transfusion mix-up

A nurse whose patient died after she gave him the wrong type of blood has been given a suspended sentence.

Lea Ledesma made a series of mistakes that led to Ali Huseyin, 76, being given type AB blood during a transfusion even though he was blood group O.

The nurse, who was described as the “mother” of the intensive care unit at London Heart hospital, where she had worked since 2001, then tried to blame a colleague for the mistake.

She was given an 18-month suspended sentence at Southwark crown court, after previously being convicted of unlawful manslaughter by gross negligence.

Ledesma, 49, of Stevenage in Hertfordshire, wept and hugged her family after the sentence was passed on Thursday.

The public gallery was packed with dozens of her relatives, friends and former hospital colleagues, many of whom wrote letters of support to the court.

They formed a circle and prayed after the judge announced she would not be going to prison.

Huseyin had been in the care of Ledesma after a successful heart bypass operation in May 2014. He was given the wrong blood type on 7 May 2014 and died later the same day.

Ledesma made several errors, the court heard, including choosing the wrong blood from a vending style machine before checking it against the wrong computer records.

Ledesma initially tried to pass off the error as being a colleague’s mistake and only when questioned further did she admit to being distracted and flustered when checking the patient’s details.

Anthony Metzer, defending, described the case as a “double tragedy” and said Ledesma was “anxious to accept full blame” and had shown extreme remorse.

“Even to this day, I don’t think there’s anything I can point to as to how it was that this tragic and serious error came about,” he said. “This will live with her until her own dying day.”

The judge, Nicholas Loraine-Smith, said: “Mr Huseyin was a much-loved husband, father and grandfather – a kind, considerate family man whose death has devastated his family, particularly his wife, who feels so alone without him after all these years.

“It’s still a mystery to me as to how and why you came to behave in the way that you did, and you remain certain that the details of the other Mr Hussain were shown on the deceased’s monitor and I cannot exclude that as a contributory factor.”

Loraine-Smith said he had “rarely, if ever” seen so many character references and letters of support for a defendant. “You were committed to that unit,” he said. “Everybody talks about how reliable you were, how committed. You were described as the mother of the unit and always prepared to go the extra mile for your patients.”

Nurse gets suspended sentence over fatal blood transfusion mix-up

Ebola nurse suspended after falsifying Pauline Cafferkey"s temperature

The nurse who was found to have concealed her colleague Pauline Cafferkey’s raised temperature before she tested positive for Ebola in 2014 has been suspended from practising for two months.

An independent Nursing and Midwifery Council (NMC) panel had found that Donna Wood was a low risk to future patients but that her fitness to practise had been impaired and a sanction was in the public interest.

Najrul Khasru, the chair of the panel, told Woods that an aggravating factor was that: “The seriousness of your misconduct … could have contributed to the risk of Ebola, a very serious and dangerous illness spreading in this country.”

The panel described Wood’s “dishonesty” as “extremely serious” but told her it was “not premeditated but a momentary lapse of judgment”.

The sanctions were imposed after an eight-day hearing in Stratford, east London, after Public Health England, which was running the screening process in Heathrow, reported her for allegedly falsifying a document recording Cafferkey’s temperature as one degree lower than it was.

Wood was returning from Sierra Leone, where she and Cafferkey had volunteered to work in an Ebola treatment centre at the peak of the epidemic in December 2014.

Khasru said her misconduct had been an “isolated incident in an otherwise unblemished nursing career … and unlikely to be repeated”.

The panel found that Wood had not misrecorded Cafferkey’s temperature on a health screening form, but said she had known it was elevated and had not escalated this despite knowing that a high temperature was a potential early warning sign for Ebola.

In not doing so, she had “put Ms Cafferkey and anyone coming into contact with her at at unwarranted risk of harm”, said Khasru.

In considering what sanctions to impose, Khasru said the panel took into account the stress and exhaustion of the nurses, who had been working up until the day they left Sierra Leone.

It concluded that striking Wood off would be have been disproportionate, and it was in the public interest to retain a highly skilled nurse. Wood currently works as an end-of-life nurse in Burslem, Stoke-on-Trent.

Among the mitigating factors were Wood’s previous good record and her “selfless act” to volunteer to help Ebola patients in Sierra Leone.

The panel also noted the “less-than-ideal environment in the screening area” at Heathrow airport when the passengers returned from west Africa on 28 December 2014.

Khasru noted that Wood had worked as a nurse for two years since the incident without any concerns raised during this period or throughout her 29-year career.

But the panel said her behaviour, though a momentary lapse of judgment, warranted a suspension in order to uphold the public’s confidence in the profession.

“The panel was mindful of its duty to protect the public interest. This includes the protection of patients and others, maintenance of public confidence in the profession and the regulatory body,” Khasru said.

It emerged during the disciplinary hearing that the group of five volunteers including Cafferkey and Wood had decided to take their own temperatures in order to get out of the “uncomfortable” and “chaotic” screening area more quickly.

Cafferkey and her colleagues were cleared to go through to the baggage area but Cafferkey later returned to the screening area after a doctor in their volunteer group raised concerns.

She was subsequently given the go-ahead to take her connecting flight to Glasgow, but the senior clinician on the team was not aware she had taken paracetamol, which can mask a high temperature, the tribunal had heard.

Ebola nurse suspended after falsifying Pauline Cafferkey"s temperature

Young people living in a "suspended adulthood", finds research

Despair, worries about the future and financial pressures are taking a toll on millions of young Britons, according to a major new poll that also found young women were suffering in particular.

Low pay and lack of work in today’s Britain are resulting in “suspended adulthood”, with many living or moving back in with their parents and putting off having children, according to the poll of thousands of 18 to 30 year-olds.

Large numbers describe themselves as worn down (42%), lacking self-confidence (47%) and feeling worried about the future (51%).

The Young Women’s Trust, the charity that commissioned the polling by Populus Data Solutions, warned that Britain was facing a “generation of young people in crisis” as it called on the government to take steps including creating a minister with responsibility for overall youth policy.

Young women are being particularly affected. The percentage of them reporting that they lack self-confidence was 54%, compared with 39% of young men.

While four in 10 young people said they feel worn down, the percentage for young women was 46% compared with 38% of young men. One in three said they were worried about their mental health, including 38% of young women and 29% of young men.

Dr Carole Easton, the chief executive of Young Women’s Trust, which supports and represents women aged 16 to 30 struggling to live on low or no pay in England and Wales, said that it was distressing that so many young people were struggling at a time of life traditionally characterised by youthful confidence.

“Make no mistake about it, we’re talking about a generation of young people in crisis. And while life is hard for many young people, our survey shows it’s likely to be considerably tougher if you are a young woman,” she said.

“It’s not in any of our interests to write off an entire generation. Much more needs to be done to improve young people’s prospects, including through creating a minister for young people, extending the National Living Wage to under 25s, delivering on government commitments to improve housing options for young people and tackling workplace discrimination.”

Of 4,000 18 to 30 year-olds, the No Country for Young Women study found that 43% of those polled still live at home and a quarter had to move back in with their parents because they couldn’t afford to live independently. As much as 56% of them said they would consider moving abroad for work.

The charity is also calling for a commitment from government to move towards extending the National Living Wage to under 25s and a greater focus, including through JobCentre Plus, on supporting young adults – especially young women.

Young people living in a "suspended adulthood", finds research

Principal Investigator Of Suspended Cytori Stem Cell Trials Stays Hopeful

Shares of Cytori Therapeutics took a large bit hit these days right after the business disclosed in a press release that it had suspended enrollment in its ATHENA and ATHENA II trials. This type of information is never ever a excellent sign, but the   principal investigator of the trial tells me that he believes the recent problems are surmountable and that the trials are nonetheless viable.

The twin trials are each testing Cytori’s adipose-derived regenerative cells (ADRC) towards placebo in 45 patients with sophisticated heart illness who are not eligible for bypass surgical treatment or stents. The trials are testing a 2 stage process. In the morning the individuals undergo liposuction to harvest a tiny quantity of body fat, which is then processed to isolate the ADRCs. Later on in the day the patients undergo cardiac catheterization in the course of which time the heart is imaged in detail and the ADRCs injected in the target areas.

In its press release Cytori announced that enrollment in the trials had been suspended:

The choice to spot the trials on hold was based mostly on a safety evaluation of reported cerebrovascular occasions. Signs and symptoms occurred in three individuals, of which two patients’ signs and symptoms totally resolved within a quick time period of time and the third patient has had considerable resolution of signs and symptoms. This kind of occasions had not been previously reported in Cytori’s other cardiovascular trials and appear to be connected in portion to the healthcare co-morbidities in the treated population and the complex nature of the procedures involved in the trial.

Timothy Henry, the co-principal investigator of the trials, presented some additional info and perspective in an interview. The three cases had been “temporally related” to the procedures and were classified as strokes due to the fact they lasted longer than 24 hours. In two of the circumstances the signs and symptoms have been fully reversed. The third patient nevertheless has some remaining minor deficits.

Henry, who is also the director of cardiology at Cedars-Sinai, pointed out that these type of complications generally happen with any invasive cardiac process and that sufferers with advanced disease are specifically prone to these complications. He explained that these individuals had fewer complications than related patients undergoing bypass surgical procedure or TAVR.

Darrel Francis, a United kingdom cardiologist who has been critical of much stem cell research, told me that a very likely source of the issues was the use of electroanatomical mapping, which involves moving the catheter all around in the left ventricle to discover a great area to deal with. “Dangling catheters in the left side of the heart does have a stroke chance, and is observed – for illustration – in AF ablation,” he said.

An additional important role in the complications was almost undoubtedly played by anticoagulants employed ahead of, for the duration of, and after the process, he stated.

Henry also said that the DMC had told him that the 3 events occurred in each the treatment and placebo groups, although of program he is still blinded to the certain therapy assignments.

Henry stated the DMC (Data Monitoring Committee), Cytori, and the FDA have all completed their jobs correctly. “Everybody did what they have been supposed to do,” he mentioned. The trial was actually stopped about two months in the past. Yesterday’s announcement came after the FDA explained it had added concerns for the firm and the investigators. Henry explained he is hopeful that the trial may possibly be capable to resume in about two months.

A single idea below discussion is to enroll significantly less sick individuals. Simply because the recent patient population is quite sick they are at higher chance for complications. He mentioned they are considering producing the trial a lot more restrictive, cutting out patients with atrial fibrillation and quite reduced ejection fractions, for instance. A healthier population would be much less susceptible to these complications. Of course the downside of such a approach is that it would reduce the electrical power of the trial to detect a remedy effect.

The overarching concern, which should definitely haunt the thoughts of the FDA and of investigators as well, is that the stem cell treatment is ineffective but that the procedure to deliver the treatment brings about harm.

Francis provided the following comment:

Whilst it is always unhappy to hear that individuals have suffered by means of volunteering in the interests of furthering science, in this situation it is a relief to hear that 2 of the 3 have presently recovered. It is cautiously performed analysis, and patient volunteers, who make the slow forward actions of science achievable. Cell treatment has an enviably benign safety record. Certainly some cell treatment advocates seem to consider delight (paradoxically in my see) in pointing out that the cells really do not persist within the heart: they apparently vanish, leaving just an unexplained benefit. How may well disaggregated cells cause problems of this nature in this study? That is why the target will be on the sum of intraventricular catheter manipulation necessary, and the linked want for anticoagulation. These investigators are setting a very good instance of openness which will aid advance the discipline, for the ultimate benefit of individuals.

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Principal Investigator Of Suspended Cytori Stem Cell Trials Stays Hopeful