Hundreds of patient samples lost from Northern Ireland hospitals

HUNDREDS of medical samples taken from patients to test for infection, disease and even cancer have been lost in hospitals throughout Northern Ireland over the last five years, The Detail can reveal.

The samples were mostly blood specimens but also included bodily waste, biopsies and other human tissue. In some cases patients will have had to undergo invasive procedures for a second time after samples went missing while being transported between laboratories.

Over the last five years 365 specimens have gone missing from hospital buildings or during transportation.

In Belfast hospitals alone 348 samples were recorded by the Belfast Health Trust as “missing”. Over half were never found again.

Responding to the figures highlighted by The Detail today a spokesperson for the Belfast Health Trust said: “We are very sorry if this has been a cause of concern or stress to any of the patients affected.”

However the trust also said that it handles millions of samples every year and only a small percentage could not be traced.

But the chair of the British Medical Association (BMA) in Northern Ireland, Dr John Woods, told The Detail that cases of specimens going missing were “never acceptable”, regardless of the numbers involved.

"It is worrying that any medical specimen would go missing. These are often crucial in making a diagnosis and guiding treatment. It is especially concerning when specimens are lost which have been obtained by an invasive procedure which then has to be repeated.

"The number of specimens going missing may be small given the numbers processed but this is never acceptable."

Patient samples taken in hospitals are usually transferred using internal NHS systems.

However The Detail has established that a number of lost samples were accidentally sent out in the post.

Internal hospital investigations, including some Serious Adverse Incident (SAI) inquiries, were triggered on a number of occasions, including when:

• Two samples were put into a brown envelope and inadvertently sent out in the post from the South West Acute Hospital in Enniskillen;
• Two samples from Altnagelvin Hospital were accidentally posted to Stormont Parliament Buildings;
• The Belfast Trust did not return what was referred to as a specimen to Altnagelvin hospital. It was temporarily recorded as lost. When it was found the specimen was cremated;
• Samples from a deceased person, biopsies from oral surgery and tissue remains were lost from the Southern Trust;

We asked each trust how many samples taken from patients for tests had been lost by hospitals within their catchment area.

The figures show that over the last five years 365 specimens have been lost. Over 60% were never found again. The overwhelming majority of lost specimens, which were never found again, were recorded by the Belfast Trust with 220 such losses.

Where samples were lost in the Belfast Trust
Wards	15
Labs	32
Not identified	64
When being transported	109

Blood samples were the most common specimen recorded as lost in the Belfast Trust. Other missing samples included:

• Urine samples to check for kidney infections and monitor renal disease in diabetes patients;
• Faeces samples to look for the presence of parasites or detect the presence of blood as a possible symptom of bowel cancer;
• Swabs used to sample a wound, to look for evidence or the presence of infection;

The Belfast Trust confirmed that some lost samples will have led to patients undergoing invasive procedures for a second time.

It also confirmed that among the lost samples recorded was cerebrospinal fluid (CSF). A lumbar puncture procedure is needed to obtain a sample of this fluid which surrounds the brain and is also present in the spinal canal.

This procedure is used to diagnose conditions such as meningitis or a brain haemorrhage.

"UNNECESSARY STRESS"

While the majority of samples went missing from Belfast hospitals, there were a number of instances of samples going missing from within other health trusts.

Seven samples were lost from hospitals in the Western Trust.

A Serious Adverse Incident (SAI) investigation was triggered after two samples were put into a brown envelope and inadvertently sent out in the post from the South West Acute Hospital in Enniskillen.

The Western Trust said that the samples were eventually retrieved and procedures were modified so that only designated specimen bags would be used in the future.

Two biochemistry samples from Altnagelvin Hospital were also accidentally sent to Stormont’s Parliament Buildings. When they were returned to Altnagelvin they were no longer viable and the tests had to be repeated. The trust said it was not able to ascertain why the samples were sent to Stormont.

A further specimen was cremated after the Belfast Health Trust did not return it to Altnagelvin when it became temporarily lost.

The Belfast or Western Trust would not provide further information on this incident due to the risk of identifying an individual patient but the Western Trust confirmed that it was raised as a Serious Adverse Incident and that additional tracking procedures had since been put in place.

In a statement the Western Trust said: “The trust very much regrets the loss of pathology referral samples and the unnecessary stress and concern this would cause to patients. All specimens that are lost are thoroughly investigated in order to ascertain the cause of the loss and what corrective actions are required.

“The trust deals with many thousands of samples each year and experiences a very small number of losses annually.”

The Southern Trust recorded six cases of missing samples that included tissue samples from a deceased patient and two biopsies from oral surgery. All but one of the samples were recovered.

A spokesperson for the Southern Trust said: "In the last five years, a small number of samples from patients in the Southern Health Trust were unfortunately lost. Almost all of the samples were recovered and no patients were placed at risk.

"Each incident was reviewed and changes made to our procedures to minimise the possibility of it happening again. We apologise for any distress caused to patients and their families by the loss of these samples.”

Out of four samples which went missing from hospitals in the South Eastern Trust area two were never found again. In both cases the specimens were meant to be sent from the Ulster Hospital in Dundonald to Belfast’s Royal Victoria Hospital for further tests but they never arrived.

The Northern Trust said it had no reported incidents of patients’ samples being lost.