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

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