Human Tissue Authority

The regulator for human tissue and organs

Human Application – Serious Adverse Events closed in Q3 2020/21 – details

Licence

Number

Organisation

Case Number

Process Event Linked To

Description of Event

11094

University Hospital of Wales

CAS-56529-Y6X7

Procurement

Donor factors may have

contributed to clotting of unit

resulting in low cell viability

11063

BioVault

CAS-56315-M7C2

Procurement

Unlicensed procurement

11036

SCI Sheffield

CAS-48909-C7C1

Testing

Cleared donor tested positive on

day of donation for non-mandatory

marker

11025

University College London

Hospitals

CAS-56303-X5X8

Procurement

Positive microbiology on procured

unit

22518

NHSBT Bristol

CAS-56631-H4G8

Procurement

Positive sterility on procured unit

11017

SCI Leeds

CAS-54278-K8H9

Procurement

Positive microbiology on procured

unit

22513

Anthony Nolan

CAS-56981-G8L8

Testing

Donor testing protocol not followed

22620

Sheffield Teaching Hospitals

NHS Foundation Trust

CAS-54984-N1Y1

Procurement

Positive microbiology test result on

procured unit.

22518

NHSBT Bristol

CAS-55856-L6M6

Other (please specify)

Human error led to the request for

an unnecessary procurement

11135

Royal National Orthopaedic

Hospital

CAS-55906-N3W9

Distribution

Incorrect release of a unit.

11061

Birmingham and Midland

Eye Centre

CAS-55424-K9J2

Transportation

Human error resulted in the loss

of tissue

11061

Birmingham and Midland

Eye Centre

CAS-55427-T9P3

Other (please specify)

Lack of equipment resulted in the

loss of tissue

11052

The London Clinic

CAS-56288-S4M7

Procurement

Positive microbiology test result

post-processing

22513

Anthony Nolan

CAS-56820-Z0H8

Processing

Human error led to the import of

cells with incomplete processing

details

22513

Anthony Nolan

CAS-56281-X7Q7

Procurement

Positive microbiology test result

on procured unit.

22513

Anthony Nolan

CAS-55217-S0S7

Testing

Release of tissue with incomplete

testing results.

22513

Anthony Nolan

CAS-55239-Q1K9

Procurement

Positive microbiology test result on

procured unit.

22513

Anthony Nolan

CAS-55739-V3H9

Testing

Day of collection sample

seropositive for non-mandatory

disease marker.

22518

NHSBT Bristol

CAS-55979-K0C5

Procurement

Positive microbiology test result on

procured unit.

22513

Anthony Nolan

CAS-56228-N3B8

Procurement

Positive microbiology test result on

procured unit.

11063

BioVault

CAS-56102-V8W1

Procurement

Human error caused the loss of

the sample.

22610

Sunderland Royal Hospital

CAS-54821-J4P6

Transportation

Unauthorised transport of an

allograft.

11052

The London Clinic

CAS-51620-W0N4

Procurement

Positive microbiology test result on

procured unit.

11052

The London Clinic

CAS-53367-K0C1

Procurement

Positive microbiology test result on

procured unit.

11052

The London Clinic

CAS-53492-Z0Y9

Procurement

Positive microbiology test result on

procured unit.

11052

The London Clinic

CAS-53573-K1J9

Procurement

Positive sterility result on procured

unit

11052

The London Clinic

CAS-54065-H2D0

Procurement

Positive microbiology test result on

procured unit.

11052

The London Clinic

CAS-54510-G7C4

Procurement

Positive microbiology test result on

procured unit.

11052

The London Clinic

CAS-54634-V0W1

Procurement

Positive microbiology test result on

procured unit.

11052

The London Clinic

CAS-54766-F1B7

Storage

Positive microbiology on

procurement

11052

The London Clinic

CAS-54855-N6J6

Procurement

Positive microbiology test result on

procured unit.

11052

The London Clinic

CAS-55812-T0Y8

Processing

Positive microbiology test result on

procured unit.

11052

The London Clinic

CAS-55912-P4Y1

Procurement

Positive microbiology test result on

procured unit.

11052

The London Clinic

CAS-56227-F1C8

Procurement

Positive microbiology test result on

procured unit.

11052

The London Clinic

CAS-56555-X7T2

Procurement

Positive microbiology on procured

unit

22662

Joint Operations (UK) LLP

CAS-50504-Z5H9

Distribution

Tissue procured from a xenograft

recipient

11017

SCI Leeds

CAS-54822-C9L1

Materials

Loss of a cord blood unit

11063

BioVault

CAS-55576-K0Z6

Processing

Damage to bag resulted in leak

of a unit

11018

NHSBT Liverpool

CAS-55388-M7B1

Processing

Non microbial contamination

found in released tissue

22518

NHSBT Bristol

CAS-53470-C7W6

Processing

Positive microbial result on

processed tissue

11018

NHSBT Liverpool

CAS-53605-L3T4

Processing

Positive microbiology test result

11018

NHSBT Liverpool

CAS-53774-G1T4

Processing

Positive microbiology test result

22518

NHSBT Bristol

CAS-53888-Q5V9

Processing

Positive microbiology test result

22518

NHSBT Bristol

CAS-54916-M9N7

Processing

Positive microbiology test result

11018

NHSBT Liverpool

CAS-55501-S7Q9

Processing

Positive microbiology test result

11130

Royal Gwent Hospital

CAS-55617-G0T8

Other (please specify)

Human error resulted in release

of incorrect unit.

11018

NHSBT Liverpool

CAS-55165-X4N1

Other (please specify)

Positive microbiology test result

on procured unit.

22527

Anthony Nolan Cord Blood Bank

CAS-54505-M8Q3

Testing

Loss of traceability of maternal

blood samples.

11053

SCI Southampton

CAS-56126-B5B9

Other (please specify)

Loss of a unit of cells.

12462

St George's Hospital

CAS-56271-H8M5

Other (please specify)

Loss of a unit of cells.

22518

NHSBT Bristol

CAS-56311-W7H8

Procurement

Positive microbiology test result

post-processing.

11042

SCI Oxford

CAS-56846-T8X8

Procurement

Positive microbiology test result

on procured unit

11053

SCI Southampton

CAS-56245-R3W4

Processing

Human error led to the loss of

two units of cells.

11066

Addenbrooke's Hospital

CAS-56685-R0T0

Processing

Leakage of stem cells.

22513

Anthony Nolan

CAS-57097-Y2T8

Procurement

Donor reaction during procurement.

11073

Nottingham University Hospitals

City Campus

CAS-55600-Z3N0

Other (please specify)

Human error led to loss of sample.

11066

Addenbrooke's Hospital

CAS-55845-K4W3

Other (please specify)

Leakage of stem cells.

22513

Anthony Nolan

CAS-55725-R7T8

Testing

Initial sterility check post-processing

was positive

11053

SCI Southampton

CAS-55641-S1Z0

Processing

Initial sterility check post-processing

was positive.

11041

SCI Birmingham

CAS-56495-G4J5

Procurement

Positive microbiology test result

on procured unit.

11005

Birmingham Children's Hospital

CAS-55265-W1K8

Other (please specify)

Positive sterility of allograft

potentially acquired at time

of use

22620

Sheffield Teaching Hospitals

NHS Foundation Trust

CAS-45118-W3R9

Procurement

Positive microbiology test result on

procured unit.

22620

Sheffield Teaching Hospitals

NHS Foundation Trust

CAS-50866-Z6G5

Procurement

Positive microbiology test result on

procured unit.

22620

Sheffield Teaching Hospitals

NHS Foundation Trust

CAS-45611-N0G5

Procurement

Positive microbiology test result on

procured unit.

22620

Sheffield Teaching Hospitals

NHS Foundation Trust

CAS-44866-W5R5

Procurement

Positive microbiology test result on

procured unit.

22620

Sheffield Teaching Hospitals

NHS Foundation Trust

CAS-47411-K7Z3

Procurement

Positive microbiology test result on

procured unit.

22620

Sheffield Teaching Hospitals

NHS Foundation Trust

CAS-44914-R8N0

Procurement

Positive microbiology test result on

procured unit.

22620

Sheffield Teaching Hospitals

NHS Foundation Trust

CAS-46682-B3S9

Procurement

Positive microbiology test result on

procured unit.

22620

Sheffield Teaching Hospitals

NHS Foundation Trust

CAS-54474-F0H0

Procurement

Positive microbiology test result on

procured unit.

11018

NHSBT Liverpool

CAS-52862-K6M1

Procurement

Positive microbiology test result on

procured unit.

 

Human Application – Serious Adverse Reactions closed in Q3 2020/21 details

Licence

Number

Organisation

Case Number

Donor or Recipient Affected

Description of Reaction

22518

NHSBT Bristol

CAS-53542-N2R6

Recipient

Graft failure

Last updated on: 14 Jan 2021