Human Tissue Authority

The regulator for human tissue and organs

Closed HTARIs and SAEARs in Q4 2020/21

Licence

Number

Organisation

Case Number

Process Event Linked To

Description of Event

22518

NHSBT Bristol

CAS-56429-V5Q5

Procurement

Positive microbiology on procured

unit

11094

University Hospital of Wales

CAS-55386-K7B4

Other (please specify)

Thawing protocol not followed

11031

Leicester Royal Infirmary

CAS-57911-S3F8

Testing

Positive sterility on processed

unit

11073

Nottingham University Hospitals

City Campus

CAS-57010-K4B6

Procurement

Positive microbiology test result on

procured unit

11073

Nottingham University Hospitals

City Campus

CAS-57012-V9R2

Procurement

Positive microbiology test result on

procured unit

11073

Nottingham University Hospitals

City Campus

CAS-57491-X6L7

Procurement

Positive microbiology test result on

procured unit

11094

University Hospital

of Wales

CAS-56678-S2B1

Materials

An equipment fault caused a loss

of tissue.

11063

BioVault

CAS-56770-V1H6

Storage

Human error caused the loss

of the sample

22513

Anthony Nolan

CAS-58088-Y0L4

Procurement

Positive microbiology test result on

procured unit.

22513

Anthony Nolan

CAS-57792-D2K8

Processing

Positive microbiology

test result post-processing.

11031

Leicester Royal Infirmary

CAS-57464-D0L0

Testing

Initial sterility check

post-procurement was positive

22681

NHSBT Barnsley

CAS-58613-Z1G5

Procurement

Positive microbiology

test result on

procured unit.

11017

SCI Leeds

CAS-57371-B6W0

Procurement

Positive microbiology test result on

procured unit.

22681

NHSBT Barnsley

CAS-58171-S4N8

Procurement

Positive microbiology test result on

procured unit.

22513

Anthony Nolan

CAS-56853-Z7B7

Procurement

Positive sterility on a procured

unit.

11052

The London Clinic

CAS-56852-P1H4

Procurement

Positive sterility on a

procured unit.

22513

Anthony Nolan

CAS-57326-J3P1

Processing

Human error caused loss

of sample.

22513

Anthony Nolan

CAS-57251-F3X9

Procurement

Positive microbiology test result on

procured unit.

11100

Queen Elizabeth Hospital Birmingham

CAS-57351-J7J5

Processing

Initial sterility check

post-procurement was positive.

11041

SCI Birmingham

CAS-57318-G2F4

Processing

Initial sterility check

post-procurement was positive.

11052

The London Clinic

CAS-56842-K1Q7

Procurement

Positive microbiology test result on

procured unit.

11052

The London Clinic

CAS-56945-R8V6

Procurement

Positive microbiology

test result on a procured unit.

11052

The London Clinic

CAS-57255-H4S6

Procurement

Positive microbiology test result on

procured unit.

11052

The London Clinic

CAS-57468-G5Z8

Procurement

Positive microbiology test result on

procured unit.

11052

The London Clinic

CAS-57497-X7W2

Procurement

Positive microbiology test result on

procured unit.

22513

Anthony Nolan

CAS-57769-X2W7

Procurement

Positive microbiology test result on

procured unit.

22513

Anthony Nolan

CAS-57455-B8C0

Procurement

Positive microbiology test result on

procured unit.

11052

The London Clinic

CAS-57211-C7Z0

Procurement

Positive sterility on a procured unit.

22513

Anthony Nolan

CAS-57788-D1B8

Procurement

Positive microbiology test result on

procured unit.

11122

Royal Victoria Infirmary

CAS-56890-Q8Z7

Testing

Mandatory

serology testing not conducted

within the required time frame.

11062

King's College Hospital

CAS-50926-P1Y2

Storage

Loss of tissue

due to equipment failure.

22513

Anthony Nolan

CAS-56419-F8F5

Procurement

Positive microbiology test result on

procured unit.

11017

SCI Leeds

CAS-54772-C6C2

Other (please specify)

Positive microbiology

test result on

procured unit.

22513

Anthony Nolan

CAS-55659-G5P9

Other (please specify)

Partial loss of

cells due to a clot.

11066

Addenbrooke's Hospital

CAS-55606-P8Y9

Other (please specify)

Partial loss of stem cells due to

a clot.

11005

Birmingham Children's Hospital

CAS-52707-P9F3

Other (please specify)

Positive microbiology test result on

procured unit.

11053

SCI Southampton

CAS-56898-K4N7

Distribution

Unit information not updated

11066

Addenbrooke's Hospital

CAS-56532-C9S8

Storage

Damage to bag resulted in

leakage of product.

11018

NHSBT Liverpool

CAS-55312-K4M4

Procurement

Source of

positive sterility of implanted

allograft possibly from the recipient

22513

Anthony Nolan

CAS-57611-G9X8

Procurement

Insufficient dose

of cells collected

22513

Anthony Nolan

CAS-56819-D9P2

Procurement

Positive microbiology

test result on procured unit.

22518

NHSBT Bristol

CAS-56792-V5K0

Procurement

Positive microbiology

test result on procured unit.

11063

BioVault

CAS-57604-F9Y0

Procurement

Unlicensed procurement

11024

BCH Stem Cell Bank

CAS-57262-S4X5

Preservation

Equipment issue resulted in

extended cryopreservation cycle.

11065

Gartnavel General Hospital

CAS-57782-R5B1

Other (please specify)

Small loss of cells

11119

Basingstoke and North Hampshire Hospital

CAS-58263-L8Z0

Storage

Equipment failure resulted in

loss of tissue in quarantine.

11005

Birmingham Children's Hospital

CAS-57652-M8S8

Procurement

Positive microbiology

test result on

procured unit.

11041

SCI Birmingham

CAS-57682-F3D8

Procurement

Positive microbiology

test result on

procured unit.

22518

NHSBT Bristol

CAS-56892-V5C8

Procurement

Positive microbiology

test result on

procured unit.

11053

SCI Southampton

CAS-57905-S1Z1

Processing

On day 2 of an autologous

harvest,

the units were cryopreserved

and one bag was left

in the CRF and subsequently

thawed.

The cells were lost.

22513

Anthony Nolan

CAS-57620-K1W4

Testing

Mandatory testing not

conducted within required

timeframe.

11052

The London Clinic

CAS-57640-J5Z9

Testing

Mandatory serology testing

was not conducted

within the required timeframe.

11066

Addenbrooke's Hospital

CAS-57555-F4F4

Processing

Leakage of stem cells

22638

The Royal London Hospital

CAS-56447-J1R3

Materials

Damage to bag resulting in

leakage of stem cells.

22518

NHSBT Bristol

CAS-56273-X2H9

Transportation

Stem cells not transported at

the appropriate temperature.

11010

The Jack Copland Centre

CAS-56618-K5Z0

Processing

Discrepancy in cell counts obtained

for processed unit.

22522

Smart Cells International

CAS-57439-D8K1

Preservation

Equipment failure due to

human error

11005

Birmingham Children's Hospital

CAS-50264-T4P8

Procurement

Positive microbiology test result on

procured unit

11025

University College London Hospitals

CAS-57926-R8H3

Procurement

Positive sterility

on procured unit

11006

King's College Hospital

CAS-57314-C4F6

Procurement

Leakage of

stem cells

22522

Smart Cells International

CAS-57586-N6M8

Processing

Human error resulting

in incorrect labelling

22518

NHSBT Bristol

CAS-57831-Q2S4

Recipient

PGF may be associated

with the quality of tissue issued

Last updated on: 19 Apr 2021