Independent review into heart valve bank operations
Queensland’s Heart Valve Bank will undergo an independent, external review after a significant clinical error was identified by Metro South Hospital and Health Service.
Queensland Health Director-General Michael Walsh ordered a formal Health Service Investigation after an earlier audit of the facility discovered four patients received tissue they should not have.
Mr Walsh said the initial audit had revealed tissue from a donor with a particular type of brain cancer was incorrectly released for use in heart valve and cardiac tissue grafts on those four patients early last year. The affected patients and their families have been informed.
“While I’m assured the risk to these patients is extraordinarily low, this is unacceptable and should not have happened,” Mr Walsh said.
“We have sincerely apologised to these patients and their families.
“At the request of the Minister for Health, I’ve ordered a full, independent, external review of the Heart Valve Bank to determine how and why this happened, and what measures need to be put in place to prevent it ever happening again.”
Chief Health Officer Dr Jeannette Young said patients and their families had been informed this week.
“The risk of patients developing cancer as a result of these grafts is extraordinarily low,” Dr Young said.
“After an exhaustive search of medical literature, we were not able to find an instance where anyone has developed cancer when a tissue graft has been taken from a patient with this type of brain cancer anywhere in the world.”
Dr Young said people who had cancer can still make certain donations.
“Teams of clinicians check the eligibility of all donations for use but in this circumstance this donor tissue should not have been cleared for use in heart valve and cardiac tissue grafts,” Dr Young said.
Mr Walsh said the independent, external review would determine what if any system, procedural or clinical issues contributed to the error.
The Heart Valve Bank is operated by Metropolitan South Hospital and Health Service on behalf of the entire state.
The Heart Valve Bank has been closed since January and the HHS is currently formally investigating a range of staffing issues, following a number of internal complaints.
Mr Walsh said the four patients – three children and a young adult – received heart-valve grafts last year.
An initial examination of grafts over the past five years has not identified any other issues of a similar type. The Health Service Investigation will examine this further.
The independent external review is expected to be finished by the end of the year.
NOTE: To protect their privacy, Queensland Health will not be disclosing any further details of the patients who received the grafts.
The QHVB is managed through the Queensland Tissue Banks which is part of Metro South Hospital and Health Service.
Prior to its closure, the QHVB distributed cardiovascular tissue across Queensland and interstate for use in surgery, most commonly in children and infants with congenital heart disease.
Tissues required for Queensland patients will be sourced from interstate heart valve banks until regulatory compliance can be assured.
Three staff have been stood down, pending the outcome of the separate investigations.
The Health Service Investigation will be commissioned under the Hospital and Health Boards Act 2011.
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