Mix-up sees potentially contaminated cancer tissue transplanted to babies

An urgent review of Queensland’s Heart Valve Bank has been ordered after a serious health breach. Queensland’s Department of Health has found a significant clinical error which lead to four patients, including three babies, being given tissue from a donor who had brain cancer.

Queensland Health Director-General Michael Walsh has ordered a formal Health Service Investigation after an earlier audit of the facility discovered the four patients received tissue they shouldn’t have. He explained tissue from a donor with brain cancer was incorrectly released for use. During the mix-up, the tissue was used in heart valve and cardiac tissue grafts for the four patients in early 2017. The patients and their families have been informed of the error.

Walsh said the risk of the four patients developing cancer was low.

“While I’m assured the risk to these patients is extraordinarily low, this is unacceptable and should not have happened,” he said in a statement. “We have sincerely apologised to these patients and their families.”

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He said the Queensland Minister of Health had requested a full, independent, external review of the Heart Valve Bank to figure out how and why the mistake occurred and what measures need to be implemented to ensure it never happens again.

Chief Health Officer Dr Jeannette Young said patients were informed of the error this week. Each patient had received their heart-valve grafts last year.

“The risk of patients developing cancer as a result of these grafts is extraordinarily low,” Dr Young said in a statement. “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.”

She added that people who had cancer can still make some donations and that staff usually complete checks to confirm eligibility.

“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 added.

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Walsh said the independent and external review would determine the system, procedural or clinical issues that contributed to the mistake being made. At present, the Heart Valve Bank is operated by Metropolitan South Hospital and Health Service on behalf of the state of Queensland. It has been closed since January as investigations surrounding staffing issues take place.

An initial examination of grafts dating back over the past five years has not identified any other mistakes like this, however, the Health Investigation will examine it further. It is expected that the independent external review will be complete by the end of the year.

Queensland Health said it will not disclose further details about the patients.

What do you think? Does this make you nervous about operations and surgery?