Human Tissue Authority

The regulator for human tissue and organs

Human Application – Serious Adverse Events closed in Q2 2020/21 details

Licence
Number
Organisation
Case Number
Process Event Linked To
Description of Event

22513

Anthony Nolan

CAS-49995-S2Z5

Procurement

Positive microbiology test result on procured unit.

11010

The Jack Copland Centre

CAS-55990-D9G3

Preservation

Equipment failure.

11036

SCI Sheffield

CAS-54884-L0P1

Procurement

Positive microbiology test result on procured unit.

11001

Royal Marsden Hospital

CAS-55891-X4Y7

Procurement

Positive microbiology test result on procured unit.

11100

Queen Elizabeth Hospital Birmingham

CAS-53835-R4C6

Procurement

Positive microbiology test result on procured unit.

11018

NHSBT Liverpool

CAS-54306-D7W4

Processing

Positive microbiology test result on procured unit.

22505

Chapel Allerton Hospital

CAS-55731-S6G7

Storage

Incorrect temperature measurement resulted in the disposal of tissue.

22656

NuVision Biotherapies Limited

CAS-55858-Z5C0

Distribution

Weather issues affected the timely distribution of tissue.

22518

NHSBT Bristol

CAS-55435-W5B7

Other (please specify)

Damage resulted in product leakage and disposal of unit.

11042

SCI Oxford

CAS-50421-Q9D6

Procurement

Positive microbiology test result on procured unit.

11073

Nottingham University Hospitals City Campus

CAS-54464-M9P8

Other (please specify)

Damage to bag resulted in disposal of unit.

22513

Anthony Nolan

CAS-54885-S2S6

Materials

Leakage of stem cells.

22518

NHSBT Bristol

CAS-54109-W4S5

Procurement

Positive microbiology test result on procured unit.

22522

Smart Cells International

CAS-55682-Z2Z5

Procurement

Human error resulted in the tissue being packaged inappropriately.

22513

Anthony Nolan

CAS-54962-S2Z9

Procurement

Positive microbiology test result on procured unit.

22533

Heartlands Hospital

CAS-55828-G8P1

Procurement

Positive microbiology test result on procured unit.

22596

Manchester University NHS Foundation Trust - Central Hospitals

CAS-55172-S3M5

Other (please specify)

Tissue with incomplete testing results issued for transplantation.

11053

SCI Southampton

CAS-55417-W1B4

Procurement

Positive microbiology test result post-processing.

11081

The Christie

CAS-53841-F9P8

Procurement

Positive microbiology test result on procured unit.

11053

SCI Southampton

CAS-54970-G8G5

Procurement

Positive microbiology test result on procured unit.

11036

SCI Sheffield

CAS-55276-Z5L7

Procurement

Positive microbiology test result on procured unit.

11053

SCI Southampton

CAS-52082-T8W1

Testing

Initial microbiology test post-processing was positive but clear on re-testing.

22526

Wessex Blood and Marrow Transplant Unit (Adult & Paediatric)

CAS-52018-B2N0

Testing

Initial microbiology test post-processing was positive but clear on re-testing.

11081

The Christie

CAS-53802-V6B8

Transportation

Temperature limits for storage of units (on ward) exceeded due to extended infusion time.

22586

Wescott Medical Ltd

CAS-53805-H7P7

Other (please specify)

Tissue not suitable for use.

22513

Anthony Nolan

CAS-55923-Q8X2

Procurement

Positive microbiology test result on procured unit.

11093

Derriford Hospital

CAS-54561-H4Q7

Processing

Positive microbiology test result on procured unit.

22513

Anthony Nolan

CAS-52661-B4D2

Procurement

Positive microbiology test result on procured unit.

11093

Derriford Hospital

CAS-52636-V9N0

Procurement

Positive microbiology test result on procured unit.

11041

SCI Birmingham

CAS-53748-L0T6

Procurement

Positive microbiology test result on procured unit.

11063

BioVault

CAS-55302-T1X7

Procurement

Unlicensed procurement.

11017

SCI Leeds

CAS-53646-B5B2

Distribution

Incorrect release of a unit.

11017

SCI Leeds

CAS-54717-Y5Z4

Storage

Loss of a unit of stem cells due to a damage of the bag.

11048

Royal Brompton Hospital

CAS-52668-K6T5

Materials

Loss of units, remaining units stored under concession due to non-conforming consumables.

22513

Anthony Nolan

CAS-53690-D6K1

Procurement

Positive microbiology test result on procured unit.

11036

SCI Sheffield

CAS-53718-F8D6

Procurement

Positive microbiology test result on procured unit.

11069

London Bridge Hospital

CAS-54877-D3Y1

Transportation

Loss of a unit.

11081

The Christie

CAS-53696-G8W2

Procurement

Human error caused the loss of the sample.

11081

The Christie

CAS-53698-W2C6

Procurement

Positive microbiology test result on procured unit.

11001

Royal Marsden Hospital

CAS-56229-F2P9

Materials

Reagent stored outside the required temperature range.

11041

SCI Birmingham

CAS-55238-V0D9

Distribution

The wrong product was released and thawed for end use. This resulted in disposal of the tissue.

11100

Queen Elizabeth Hospital Birmingham

CAS-55324-P0P4

Other (please specify)

The transplant centre did not thoroughly check information on the unit during the two person check and the unit was thawed incorrectly, leading to disposal of the unit.

11017

SCI Leeds

CAS-51893-S3G9

Processing

An equipment fault caused a loss of tissue.

22513

Anthony Nolan

CAS-54116-Y6T8

Procurement

Positive microbiology test result post-processing.

22513

Anthony Nolan

CAS-55353-X2C6

Testing

Mandatory serology testing not performed.

11052

The London Clinic

CAS-55341-V6T9

Testing

Mandatory testing not carried out.

22513

Anthony Nolan

CAS-54486-R8Z6

Procurement

Positive sterility on procured unit.

 

 

Last updated on: 13 Oct 2020