A bone marrow transplant patient died from a virus after a "transcription error" resulted in St James's Hospital failing to monitor her for it, an inquest has heard.
A verdict of medical misadventure was returned at the inquest into the death of Barbara Kozyra after Dublin Coroner's Court heard a transplant co-ordinator mistakenly marked her down as negative for cytomegalovirus (CMV). A common virus which can lie dormant, CMV can be reactivated and become dangerous when someone is immunosuppressed post-transplant.
Mrs Kozyra (32), who was originally from Poland and living in Loughmacrory, Omagh, Co Tyrone, underwent an allogeneic [unrelated] stem cell transplant at St James’s Hospital on August 16th, 2013. She suffered complications following the procedure including developing CMV, which led to her death on October 5th, 2013.
Consultant haematologist Dr Eibhlin Conneally told the Dublin coroner that, had the error not been made, they would have monitored Mrs Kozyra for CMV following her transplant and "pre-emptively" treated her. But because she was marked down as being CMV negative, as was her donor, the chances of her developing it were "negligible", she said. Most transplant units would generally not monitor for CMV reactivation in that situation, she told the coroner.
Mrs Kozyra needed the transplant having been diagnosed at Belfast City Hospital with myelodysplastic syndrome – a bone marrow stem cell disorder. A family match could not be found for her and Northern Ireland does not carry out unrelated donor bone marrow transplants so she was transferred to St James's Hospital in January 2013.
The error was made in Dublin when the bone marrow transplant assessment and allogeneic-matched unrelated donor recipient procurement forms were completed. Dr Conneally said this involves an independent dual sign-off of the pre-transplant information by the transplant co-ordinator and the patient’s consultant haematologist.
“In the sign-off it was noted, erroneously in hindsight, that the donor and the recipient were both CMV negative. The initial error in transcription was made by the bone marrow transplant co-ordinator and the error was not picked up in the second sign-off carried out by the consultant haematologist,” she said.
Testing protocol
It had been noted previously that Mrs Kozyra had been exposed to CMV but Dr Conneally said the transplant sheet is formulated from the results of the most recent testing.
“The error was made based on a misinterpretation of that result. It was just written down wrong. It was a transcription error,” she said, adding that testing would have been automatic if she had been marked as being CMV positive.
Coroner Dr Brian Farrell said retrospective testing on Mrs Kozyra's blood samples indicated the virus was reactivating post-transplant. Dr Conneally said she would have been treated with anti-CMV therapy but "that did not happen because the tests were not done".
Pathologist Dr Ciarán Riain said death was “due to the effects of disseminated CMV infection including severe diffuse CMV pneumonitis which occurred in the setting of immunosuppression” following the transplant.
The court heard that St James’s Hospital now automatically screens post-transplant patients for CMV regardless of whether they have had it before or not. In addition, all sections of the transplant form must now be signed by the transplant co-ordinator and consultant haematologist.