issue-45-summer-2015

June 2015 • Issue 45
Information for hospitals served
by NHS Blood and Transplant
Inside
Patient Blood Management (PBM) in Clinical
Haematology Conference Resume 4
2014 Survey of Intraoperative Cell Salvage: Equipment
and Practice Across the United Kingdom 6
Blood Stocks Management Scheme: Still value
after all these years? 8
Harvey’s Gang: Putting Patient Blood Management
in the Heart of the Hospital Transfusion Laboratory 10
Involving, Informing and Consenting Patients
Receiving Red Cell Transfusion 12
Remote Allocation of Platelets 14
Audit of Antenatal Immunisation with K 16
National Comparative Audit of Anti-D
Immunoglobulin Prophylaxis 18
The Introduction of a Regional Road Map to Improve
Access to Therapeutic Apheresis Services in the North
West of England and North Wales 19
Case Study 22
Haemoglobinopathies and Genotyping 23
The Order of St John Award for Organ Donation 25
CPD Questions 27
Clinical Case Studies 29
Diary Dates 31

Editorial Board:
Rob Webster
Consultant Haematologist, (Editor)
NHSBT, Sheffield
Email: robert.webster@nhsbt.nhs.uk
Lynne Hodkin
Medical Secretary/PA, (Editorial Assistant)
NHSBT, Sheffield
Email: blood&transplant@nhsbt.nhs.uk
Denise Watson
Regional Lead: Patient Blood Management Team
NHSBT, Newcastle
Email: denise.watson@nhsbt.nhs.uk
James Neuberger
Associate Medical Director
Organ Donation and Transplantation, Bristol
Email: james.neuberger@nhsbt.nhs.uk
Penny Richardson
Media and PR Manager
NHSBT, Liverpool
Email: penny.richardson@nhsbt.nhs.uk
John Girdlestone
Head of Laboratory
Stem Cells and Immunotherapies
NHSBT, Colindale
Email: john.girdlestone@nhsbt.nhs.uk
Paul Rooney
R&D Manager, NHSBT Tissue Services
NHSBT, Liverpool
Email: paul.rooney@nhsbt.nhs.uk
Please let us know if the mailing address for your copy
of Blood and Transplant Matters is not correct
contact: blood&transplantmatters@nhsbt.nhs.uk
Next Edition
Issue 46 will feature articles on:
• National Survey on the Use of O RhD Negative Blood
• Fetal Genotyping (ffDNA)
• ECMO Support Group
• Wellcome – The Man with the Golden Blood.
If you would like to comment on any of the articles in this edition of Blood and Transplant Matters
please email the Editor: robert.webster@nhsbt.nhs.uk
< 2 Blood and Transplant Matters – June 2015

EDITORIAL
NHS Blood and Transplant
describes itself as a Special Health
Authority, dedicated to saving and
improving lives through the wide
range of services we provide to
the NHS. Since joining NHS Blood
and Transplant as Chief Executive
last summer, I have been seeing
first hand and learning from
colleagues in their workplaces just
how wide that range of services
is. I have also been pleased to
meet a great number of people who work in the hospitals that
we serve and others who support the vital work that we do.
Our blood service, supplying hospitals in England and North
Wales, relies on the generosity of over 6,000 blood donors each
day, to make sure we are able to meet the needs of patients.
During my first months in post, I have seen how much care is
taken of this precious commodity. NHS Blood and Transplant’s
Patient Blood Management team works with colleagues in
hospitals to help to improve transfusion practice and contrary
to most organisations, to encourage our ‘customers’ to use
less of our product. In this issue, Andrea Harris reports on the
presentations from the Patient Blood Management in Clinical
Haematology Conference that took place in Birmingham at the
end of 2014.
The Blood Stocks Management Scheme (BSMS) receives data
from blood services and hospitals in the UK and the Republic of
Ireland, through VANESA, a specialist data management system.
Elaine MacRate, BSMS Manager demonstrates how participants
are also able to view data and charts on platelets and red cell
issues, stock and wastage in real time, allowing them to compare
their performance against other participants. She also reminds us
that improving inventory management can reduce wastage and
save money and that is something to shout about.
Another way of reducing blood use is cell salvage. Members of
the UK Cell Salvage Advisory Group report on last year’s survey
into Intraoperative Cell Salvage and the recommendations that
they have drawn up to help to improve service and practice across
the UK.
Emma Copperwaite from Ysbyty Glan Clwyd writes about
a novel solution to a platelet supply problem that arose when
her hospital’s pathology department was relocated at some
distance from their users. This solution has improved service for
their users, reduced wastage and made traceability easier. As a
declared technophile, I applaud the use of technology that has
such a positive impact.
As I looked at the contents for this issue, Harvey’s Gang
jumped out at me. In February, as mentioned in the article, I
had visited Western Sussex NHS Trust and been welcomed to
the Haematology and Blood Transfusion Laboratory by Malcolm
Robinson. I had heard first hand about their fantastic Harvey’s
Gang initiative. This wonderful scheme involves young patients
and their families in an area of their treatment they would not
usually see. This initiative has now inspired other hospitals at
home and abroad to follow their example.
Every year, the NHSBT audit team together with colleagues
from NHSBT and hospitals throughout the UK manage and
support a variety of audits. Effective clinical audit can bring
about change and improve practice. This issue reports on the
results of three audits. The first an audit commissioned by SaBTO
assessing the extent to which patients are involved in the decision
to transfuse them. The following two relate to ante and post
natal care.
Dr Sara Trompeter, a Consultant Haematologist with NHSBT
and UCH London, writes about the problems in providing blood
and continuing care for highly transfused patients. She tells us how
genotyping is now available in NHSBT’s RCI laboratories around
the country and talks about the NHSBT’s Haemoglobinopathy
Genotyping Initiative.
I have also seen the life saving treatments that our Therapeutic
Apheresis Services provides in our units around the country.
A team from NHSBT and the North West Regional Transfusion
Committee report on their project to improve patient access to
these vital services in their region.
Hearing from someone whose life has been transformed by an
organ transplant reminds me three people a day will die waiting,
as there are not enough organs available. Joyce Herdson was
diagnosed with Idiopathic Pulmonary Fibrosis in April 2012 and
her story relates how her health deteriorated over the following
months. Joyce received a life saving lung transplant on New
Year’s Day 2014 and tells us that she will be forever grateful to
her donor. If you want to help others after your death, please sign
up to the Organ Donor Register and let your family know of your
donation choice.
Only about 5,000 people a year die in circumstances where
they can potentially donate their organs and with 10,000 people
needing a transplant, it is easy to see how vital each donor and
donation is. Our final article in this issue, from Dale Gardiner and
The Reverend Canon Dr Paul Denby describes how a partnership
between the Order of St John and NHSBT led to the creation of
a new national award. The Order of St John Award is a unique
posthumous award which publically acknowledges and celebrates
the generosity of organ donors and their families.
Finally, having started with a sentence describing our purpose,
I would like to end with a sentence that states NHS Blood
and Transplant’s organisational aim. Our ambition is to be the
best organisation of our type in the world. My aim is to help us
achieve this.
Ian Trenholm
Chief Executive
NHSBT, Watford
Email: ian.trenholm@nhsbt.nhs.uk
Blood and Transplant Matters – June 2015 3 >

Patient Blood Management (PBM) in Clinical Haematology
Conference Resume
A National Patient Blood Management in Clinical
Haematology conference was held on 19th November 2014
at the Hilton Metropole Hotel, National Exhibition Centre,
Birmingham. This event was organised and facilitated
by the NHS Blood and Transplant (NHSBT) Patient Blood
Management (PBM) Practitioner Team.
The conference was opened by Professor Adrian
Newland, recently retired Chair of the National Blood
Transfusion Committee (NBTC) and Professor of
Haematology at Barts and The London NHS Trust. He
provided an overview of Patient Blood Management
explaining how ‘Better Blood Transfusion’ initiatives have
been developed in the UK over the past 16 years. Whilst
there have been great advancements in transfusion over this
time, with reductions in the amount of blood components
transfused, there remains evidence of inappropriate use
and unsafe practices. PBM is an international, evidence
based, multi-disciplinary approach to optimising the care
of patients, who might need a transfusion. In England,
PBM recommendations were launched July 2014.
Kate Jones, Head of Practice Development and
Innovation from NHSBT, presented Safety First in Blood
Donation. She discussed key safety interventions in the
blood donation process. NHSBT take 1.8 million donations
every year from just 4% of the eligible donor population,
and research is ongoing looking at what motivates
individuals to donate. All donors undergo a pre-donation
health check and haemoglobin screening. The INTERVAL
study is looking at frequency of donation. Platelet donors
can donate every two weeks (maximum 24 donations in
one year) although most donate monthly.
Tony Davies, NHSBT PBM Practitioner and member of
Serious Hazards of Transfusion (SHOT), presented Lessons
from the 2013 SHOT report. During 2013, 77.6% of all
transfusion incident reports were caused by human error,
including nine ABO incompatible red cell transfusions.
There were 22 deaths where the transfusion was causal
or contributory and 143 reports were associated with
major morbidity, including acute transfusion reactions
(including anaphylaxis, severe febrile or hypotensive),
delayed transfusion reactions, and Transfusion-Associated
Circulatory Overload (TACO, especially in patients with
contributory factors such as low body weight or renal
impairment).
Tony stressed that positive patient identification is
critical at every stage of the transfusion process, to prevent
errors due to ‘human factors’.
Emma Whitmore, NHSBT PBM Practitioner, then
provided an overview of the requirements for patient
consent, with a presentation called How informed are
you? – patient information and consent. In 2011 the
Advisory Committee for the Safety of Blood, Tissues and
Organs (SaBTO) published recommendations for patient
consent for blood transfusion. In 2012, the Department
of Health published ‘No decision about me without me’.
Individual choice is a basic human right. Patients should
have the right to decide if they want a transfusion and have
the risks and benefits explained before the transfusion
commences. PBM puts the patient at the heart of decision
making and the keys to informed consent are information
and communication.
Lorraine Birtwistle, an Advanced Haematology Nurse
Practitioner from Manchester, described her experiences
of Non-medical Authorisation of Blood Components
(NMABC). Amendments to the Medicines Act excluded
blood and blood components as medicinal products and
removed the legal barriers to nurse authorisation. In 2009,
Pirie and Green published a framework supporting the
need and rationale for NMABC to be developed and
implemented. NMABC is specifically applicable to high use
areas such as haematology, where the nurse can assess the
patient, make the decision to transfuse, organise and then
authorise or prescribe the transfusion, rather than wait for a
junior medic who has little or no knowledge of the patient.
Implementation of this extended role takes time, especially
when ‘on top of your day job’ – it took Lorraine over two
years to gain Trust agreement and to have all associated
policies in place, followed by training and competency
assessment. Benefits include a reduction in waiting times
for day patients, better planning of case loads by nursing
colleagues, improved liaison between nursing and medical
teams, and improved transfusion practice in junior medics
following her lead and practice examples.
Dr Marina Karakantza, a Consultant Haematologist
from Leeds who has a joint post with NHSBT, presented
on Management of Anaemia in Wide Spectrum
Myelodysplastic Syndromes (MDS). 98% of MDS
patients present with anaemia. 70% of these patients
present with mild anaemia. 30% present with severe
pancytopaenia, infections, bleeding, fatigue and shortness
of breath. Haemoglobin triggers for transfusion vary. Most
European centres use Hb 80-85 g/L with no co-morbidities,
and 100 g/L with cardiac or pulmonary co-morbidities.
The main objective of treating anaemia in MDS patients
is not only to relieve symptoms but to improve quality of
life and prevent ischemic organ damage. An alternative to
< 4 Blood and Transplant Matters – June 2015

ed blood cell transfusions is Erythropoietin (EPO) with or
without granulocyte-colony stimulating factor (G-CSF),
which enhances the response to EPO in some patients.
Dr Kate Pendry is a Consultant Haematologist from
Manchester, who has a joint post with NHSBT, presented
on Red Cell Transfusion Triggers – Management of
Acute Anaemia. Dr Pendry challenged the audience to
think about “How much is too much?” and “How much
is not enough?” when deciding transfusion triggers in
the treatment of anaemia. Acute anaemia has a huge
number of causes, including Gastro-Intestinal bleeding
(overt or occult), post-op bleeding, post-partum bleeding,
haemolysis, renal impairment, haematinic deficiency, bone
marrow failure, malignancy, sepsis and iatrogenic anaemia
(phlebotomy related blood loss). There is not a ‘one size
fits all’ solution, and there are multiple factors involved in
the decision making process.
Orin Lewis and Beverley de Gale from the Afro
Caribbean Leukaemia Trust (ACLT), then provided A
Patient and Relatives Perspective. This was a powerful
and emotive presentation which promoted the work of
ACLT, which was founded by Orin and Beverley when
dealing with the shortage of ethnic minority groups
donating blood, tissues, organs and bone marrow after
their son was diagnosed with leukaemia. They shared
Daniel’s story and some of the emotions, challenges and
outcomes that his illness had on their lives and, the work
that continues in his name as a legacy for others.
Dr Hazel Tinegate, Consultant Haematologist from
NHSBT, presented Managing Patients who Experience
Transfusion Reactions. Acute Transfusion Reaction (ATR)
occur in 1 in 10,000 components transfused in the UK.
Incidence varies according to type of component, with
platelets having the highest incidence. ATR is the second
most reported hazard of transfusion. Signs and symptoms
of ATR are multiple and include fever, chills, rigors, hypoxia,
dyspnoea, stridor, change in blood pressure, itch, rash,
swelling of lips, collapse, shock, change in consciousness,
reduced urine output, change in urine colour, nausea,
malaise, pain and feeling of impending doom. Different
transfusion reactions, as well as other medical conditions,
can have many overlapping signs and symptoms, therefore
diagnosis can be difficult.
Dr Andrea Harmer, National Head of NHSBT
Histocompatibility and Immunogenetics, presented
Human Leucocyte Antigen (HLA) Matching for
Platelet Transfusions. HLA-selected platelets are directed
donations for a named patient. There are different grades
of match available, and investigating these can be very
time consuming. Full matches are not possible for the
majority of patients. In order to ensure the best patient
response, it is important to have good planning, providing
NHSBT with as much notice as possible to find the best
match. Post‐transfusion platelet increment data is vital to
help inform future selections. This blood test can be taken
as little as 10 minutes after completing the transfusion.
Gillian Powter, Senior Nurse/Research Manager from
NHSBT Clinical Trials Unit then presented Assessing
Bleeding in Haematology Patients. There is a high
prevalence of bleeding in patients with haematological
malignancy; 40-50% of patients experience a bleed greater
than or equal to World Health Organisation (WHO) Grade
2. Assessing bleeding can be very subjective; one person’s
‘minor’ is another’s ‘significant’. Clinical documentation
of patient bleeding is often unreliable. A standardised
method of measuring a patient’s bleeding can be useful;
removing the differences between assessors. Bleeding
assessment forms used in clinical studies could be valuable
in daily practice too.
Finally, Dr Janet Birchall, a Consultant Haematologist
from Bristol who has a joint post with NHSBT, presented
the last presentation of the day National Comparative
Audit: Use of Platelets in Haematology (2010).
Haematology patients are the largest recipients of platelets
accounting for up to 67% of all platelets transfused. This
was the largest audit of platelet use ever reported, and
identified that 28% of all platelet transfusions audited
could potentially have been avoided. This would have
resulted in a cost saving of over 16 million pounds. In the
five years preceding the audit period platelet demand
increased by more than 20%. Following the audit results
use has increased by only 2% over the last two years.
Presentations from this conference are available on the
NHSBT Hospitals and Science website: http://hospital.
blood.co.uk/patient-services/patient-blood-management/
Andrea Harris
Patient Blood Management Lead
NHSBT, Birmingham
Email: andrea.harris@nhsbt.nhs.uk
References:
Advisory Committee on the Safety of Blood, Tissues and
Organs (2011) Patient Consent for Blood Transfusion.
https://www.gov.uk/government/publications/patientconsent-for-blood-transfusion
Bolton-Maggs, PHB. (Ed), Poles, A., Watt, A., and
Thomas, D. on behalf of the Serious Hazards of
Transfusion (SHOT) Steering Group (2014) The 2013
Annual SHOT Report. http://www.shotuk.org/shotreports/report-summary-supplement-2013/
Blood and Transplant Matters – June 2015 5 >

Department of Health (2012) Liberating the NHS: No
decision about me, without me – Government Response
to the Consultation. https://www.gov.uk/government/
uploads/system/uploads/attachment_data/file/216980/
Liberating-the-NHS-No-decision-about-me-without-me-
Government-response.pdf
National Blood Transfusion Committee (2014) Patient
Blood Management: An Evidence-Based Approach to
Patient Care. http://www.transfusionguidelines.org.uk/
uk-transfusion-committees/national-blood-transfusioncommittee/patient-blood-management
National Comparative Audit (2011) 2010 Re-Audit of the
Use of Platelets in Haematology. http://hospital.blood.
co.uk/media/26866/nca-platelet_re-audit_report-st_
elsewheres_nhs_foundation_trust_2010.pdf
The INTERVAL study
http://www.intervalstudy.org.uk/
Green, J., Pirie, L. (2009) A Framework to Support
Nurses and Midwives Making the Clinical Decision and
Providing the Written Instruction for Blood Component
Transfusion. http://www.rcn.org.uk/__data/assets/pdf_
file/0003/260832/BTFramework-Finaldraft2505092.pdf
2014 Survey of Intraoperative Cell Salvage: Equipment and Practice Across
the United Kingdom
Introduction
In 2006, the United Kingdom Cell Salvage Action Group
(UKCSAG) was established to help support the wider
implementation of cell salvage as an alternative to donor
blood and to facilitate a UK approach to its use. The group
publishes its outputs through the UKCSAG pages of the
UK Transfusion Practice Toolkit. In 2007 an initial survey
of Intraoperative Cell Salvage (ICS) practice was launched
with a repeat survey in 2010. In 2014 a further survey was
carried out. The aims of this repeat survey were:
• To evaluate progress with implementation of ICS.
• To identify remaining obstacles to the implementation
and provision of an ICS service.
• To measure the success of the UKCSAG Toolkit.
• To gain an overview of how training for ICS was being
delivered and by whom.
• To compare the clinical specialities where ICS is being
used in 2014 compared with 2010.
• To help focus future work priorities of the UKCSAG.
Methods
A survey group was established from members of
the UKCSAG. Questions were formulated by an iterative
process and also based on previous surveys carried out
by the UKCSAG. The survey was conducted as an online
exercise using SnapSurveys © software, a paper option
was also available. Answers to each question have been
analysed proportionately (number, %).
Main Findings
137 hospitals from all four countries in the United
Kingdom responded to the survey. It identified new trends
in ICS implementation. Some areas of practice identified
in the 2010 survey remain a challenge. Key findings in this
2014 survey are:
• The 2010 and 2014 surveys were distributed differently.
Accounting for this there has been little change in the
number of machines in use.
• 16% of respondents said they outsourced cell salvage
services.
• One manufacturer emerged as the most frequentlyused
machine, and was viewed as providing good
support, service and manufacturer-based training.
• Surgery in obstetrics and gynaecology is the most
frequent user of ICS with an increase in use in 2014.
• 21% said they did not operate outside normal working
hours. This has not changed since 2010.
• Staffing and lack of trained operators are cited as
reasons for no out of hours service provision.
• Operating Department Practitioners (ODP) are the main
users of ICS equipment.
• There has been a slight increase in the use of Acid
Citrate Dextrose (ACD) as an anticoagulant.
• 63% did not suction amniotic fluid (in other words it
went into waste suction).
• All ICS operators who actively use equipment, now
appear to receive training in a variety of different formats.
• ODPs, ICS Co-ordinators and manufacturers provide the
bulk of the training.
• 59% of anaesthetic trainees said they did not receive
theory or practical training (no change since 2010).
• 15% said they did not know about the UKCSAG
workbook.
• 9% said they did not know about the
learnbloodtransfusion e-learning module.
< 6 Blood and Transplant Matters – June 2015

• 16% said they had no policy for ICS in their organisation.
• 11% were not aware of the UKCSAG competency
template.
• Theatres fund the bulk of the cost of ICS.
• Local blood transfusion departments/laboratories
funded the cost of the blood.
• Between 50 and 60% of respondents said they did not
quality control the machines or the operators. However,
this represents a slight improvement since 2010.
Recommendations:
A list of recommendations have been drawn up for key
stakeholders:
For Hospitals:
• The requirement for, and provision of ICS should
be reviewed/audited by every Hospital Transfusion
Committee and be part of the programme for Patient
Blood Management/Better Blood Transfusion (PBM/
BBT) to be fully integrated into patient care.
• Every hospital providing ICS, must have an up-to-date
policy for its use.
• Recording of autologous transfusion, should have
the same stringent standards as seen in allogeneic
transfusion. The green ICS label (that is available free
from manufacturers), or hospitals own equivalent,
should be used by all hospitals carrying out ICS. The use
of addressograph labels introduces additional risk and
should be discouraged.
• Every ICS machine in use should have a service and
maintenance contract with the manufacturer, or internal
service provider, along with an agreed and documented
programme for internal quality control.
• All incidents relating to ICS should be reported to the
Serious Hazards of Transfusion (SHOT) scheme. Machine
faults should additionally, be reported as per the local
hospital policy and reported to the manufacturer at the
appropriate stage of this process and via the ‘Yellow
card’ system to the Medicines and Healthcare Products
Regulatory Agency (MHRA). Guidance on reporting
to SHOT is available at: http://www.shotuk.org/wpcontent/uploads/SHOT-Cell-Salvage.pdf
and guidance
on reporting to the MHRA is at: https://yellowcard.
mhra.gov.uk/the-yellow-card-scheme/.
• All ICS training received should be competency assessed.
For the UKCSAG:
• The UKCSAG need to raise their profile and do more
to advertise the resources available on the Toolkit; it is
recommended that they review their terms of reference
including governance arrangements and create an
annual action plan with time frames and responsibilities.
• All documentation on the ICS Toolkit should
be systematically reviewed by the UKCSAG at least once
every two years and updated if necessary.
• Further research on ICS is required and should
be encouraged and supported by the UKCSAG.
For Blood Services:
• Each of the Blood Service PBM/BBT teams should ensure
they have a named contact for cell salvage lead at every
relevant hospital in their country and ensure they are
provided with regular updates and so forth.
• Blood Services not currently doing so, could consider
bulk buying cell salvage equipment and providing
it ‘at cost’ or free to hospitals.
For College of Operating Departmental
Practitioners and Royal College of Anaesthetists:
• Education and training on ICS should be an integral part
of all programmes for ODPs and Anaesthetists.
• All ICS training received should be competency assessed.
For ICS manufacturers:
• Review the feedback in the survey and consider how
they can improve the machines, service and support
they provide to hospitals.
Karen Shreeve
Manager: Better Blood Transfusion Team
Welsh Blood Service
Email: karen.shreeve@wales.nhs.uk
Rebecca Gerrard
National Lead: Patient Blood Management
Practitioner Team
NHSBT, Liverpool
Email: rebecca.gerrard@nhsbt.nhs.uk
Hannah Grainger
Cell Salvage Coordinator: Better Blood
Transfusion Team
Welsh Blood Service
Email: hannah.grainger@wales.nhs.uk
Brian Hockley
Data Analyst and Audit Manager
NHSBT, Sheffield
Email: brian.hockley@nhsbt.nhs.uk
References:
UKCSAG online resources:
http://www.transfusionguidelines.org.uk/transfusionpractice/uk-cell-salvage-action-group
Jones, J, Howell C, 2011. Intraoperative Cell Salvage
Survey; UK Report
Blood and Transplant Matters – June 2015 7 >

Blood Stocks Management Scheme: Still value after all these years?
I have worked in blood transfusion for more years than
I would like to admit to, in large hospitals, small hospitals
and in the private sector. In all that time I have never met a
Transfusion Laboratory Manager who said ‘I really do not
care about wastage’.
When blood component wastage is discussed, you
generally get one of these replies:
• Our wastage is about the same as everyone elses.
• Yes, we have got wastage but our hospital’s challenges
are unique, it cannot be improved.
• We would like to improve it, but we just do not have the
time or the staff.
• Wastage? Not here. We do not have any at all.
Which of those categories does your hospital fall into?
Perhaps now is the time to review practice and see if
you could reduce your wastage. Not just for the donor,
because everyone who works in blood transfusion really
does value the donor. Perhaps you should consider if the
acceptance of a certain level of wastage, is costing your
laboratory money. Here, at the start of a new financial
year, why not use the Blood Stocks Management Scheme
(BSMS) database (VANESA) to demonstrate how even
slight improvements in stock management can create
‘cash releasing efficiency’ savings?
Here are some examples of how hospitals that are similar
sized, similar specialities and equivalent distance from their
centres vary in their wastage levels. These examples use
wastage data directly from VANESA,
No worse than others?
Consider three hospitals from the BSMS “Red Cell Usage – Very High” category. This shows Wastage as Percentage of
Issues by month, against a cluster of 53 hospitals that are in the same Red Cell – Very high category.
Hospital 1 Hospital 2 Hospital 3
6.0%
6.0%
6.0%
5.5%
5.5%
5.5%
5.0%
5.0%
5.0%
4.5%
4.5%
4.5%
4.0%
4.0%
4.0%
3.5%
3.5%
3.5%
3.0%
3.0%
3.0%
2.5%
2.5%
2.5%
2.0%
2.0%
2.0%
1.5%
1.0%
0.5%
0.0%
1.5%
1.0%
0.5%
0.0%
1.5%
1.0%
0.5%
0.0%
Jan-14
Feb-14
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-14
Feb-14
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-14
Feb-14
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Breakdown:
Red Cells Hospital 1 Hospital 2 Hospital 3
Issues for 2014 (Jan-Dec) (approx) 16,000 14,000 20,000
Total No of Units wasted 650 500 360
Wastage as a Percentage of Issue 4.0% 3.6% 1.8%
You can see there is a difference in wastage, let us look at the categories.
Ah, but we are different
These hospitals all have: Obstetric Unit, Oncology Unit, Orthopaedic Unit, Paediatric Unit, Renal Unit, Teaching Hospital,
Casualty, Haemophilia Unit and are “near to Blood Centre” (Delivery Time – Near)
< 8 Blood and Transplant Matters – June 2015

These are the differences:
Category Hospital 1 Hospital 2 Hospital 3
Adult & Children's Major Trauma Centre ✗ ✗ ✓
Cardio Thoracic Unit ✓ ✗ ✓
Vascular Surgery ✓ ✗ ✓
Liver Transplantation ✗ ✓ ✗
Neurosurgery ✗ ✓ ✓
Perhaps cardiothoracic surgery and vascular surgery are less blood-intensive than liver transplantation or neurosurgery?
Perhaps Hospital 3 only looks so good because they are the only trauma centre?
By selecting by category:
6.0%
Hospital 1 versus Identical cluster of clinical categories (10 hospitals)
5.5%
5.0%
4.5%
4.0%
3.5%
Taking hospital 1, and selecting by relevant clinical categories, reduces the
cluster to ten hospitals, but even so the cluster wastage is still lower. Distance
to centre doesn’t impact either
3.0%
2.5%
2.0%
1.5%
1.0%
0.5%
0.0%
Jan-14
Feb-14
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
6.0%
Hospital 2 versus Neurosurgery only category (49 hospitals)
5.5%
5.0%
4.5%
4.0%
3.5%
Neurosurgery is always a tricky one. The surgeons insist on having blood
standing by, but frequently don’t use it. This has changed hospital 2 from
being ~2% above the average, to mostly below.
3.0%
2.5%
2.0%
1.5%
1.0%
0.5%
0.0%
Jan-14
Feb-14
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
6.0%
Hospital 3 versus Adult and Children Trauma Centres (12 hospitals)
5.5%
5.0%
4.5%
4.0%
3.5%
By selecting the Adult and children’s Trauma centres as a category, it does
change the cluster (the mean is now around 3.5%) but, this hospital is just
looking even better now!
3.0%
2.5%
2.0%
1.5%
1.0%
0.5%
0.0%
Jan-14
Feb-14
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
BSMS have 13 clinical categories, combined with the other categories (distance from hospital, reservation period and
so on). It does reduce the size of the cluster for comparison, but you can add and subtract categories in VANESA when
producing these graphs, to get a more meaningful comparison. Beware of reducing cluster size too much, as with smaller
numbers in the cluster, you may get outliers skewing the data. The BSMS will soon be distributing a ‘re-registration’
exercise with some different categories to try and improve the benchmarking process.
Blood and Transplant Matters – June 2015 9 >

We just do not have the staff or time.
The BSMS really cannot help you with this one. There
are lots of suggestions about ‘good practice’ and everyone
is facing the challenges of less staff and more work these
days.
Once you have decided to do something, it has to
become an engrained habit, one that cannot be postponed.
Here are a few suggestions for your consideration:
• If its a task that no-one likes, could you set up a rota for
it? If that person is not in, then could another person
do it?
• If you already put short-dated stock in a separate
drawer, could it go in there sooner, for example with
three days left, rather than one day?
• If a clinician insists on having too many units standing by,
you could take it to the Hospital Transfusion Committee
every time you meet, to discuss the wastage it causes.
• Could you reduce your stock? The national demand has
dropped over the past two years, maybe if you hold less
stock, your wastage may reduce.
• Publicise how much you are saving the hospital by this
increased vigilance! Reducing wastage from 4% to
3.5% could save Hospital 1 nearly £10,000 per annum.
Summary
It is true that using the BSMS data will not immediately
solve your stock management problems. What it can
do is either confirm that your hospital practices are well
controlled and cannot be improved or it can identify
potential for improvement. There are lots of variables, it’s
true. These hospitals were selected only to demonstrate
the points made; there are hospitals with much higher
wastage and those who, unfortunately, don’t report on
VANESA at all.
It is important to do what is right for your laboratory
and hospital, but reducing wastage and saving money is
worth it, especially if you can use the data to prove how
well you have done. Remember, these graphs are for red
cells only, with adult platelets the costs (or relative savings)
are even higher.
So, is the BSMS still value for money? I think so, yes!
Elaine MacRate
Blood Stocks Management Scheme Manager
NHSBT, Filton, Bristol
Email: elaine.macrate@nhsbt.nhs.uk
Harvey’s Gang: Putting Patient Blood Management in the Heart of the
Hospital Transfusion Laboratory
The importance of involving and empowering patients
as part of the clinical decision making processes, is well
documented. With the introduction of the Patient Blood
Management (PBM) initiative in England and North Wales in
July 2014, they are being given greater emphasis in transfusion
practice. Demonstrating this in the transfusion laboratories is
not as easy as having a patient attending the laboratory and
engaging with laboratory staff outside of the sample tube, is
rare indeed.
In 2013 the Haematology and Blood Transfusion Laboratory
at Worthing Hospital, part of Western Sussex NHS Trust,
(WSHT) was contacted about showing a little boy around
the department. He was curious to see where his blood went
when it was tested, why it needed to be done so many times,
and how it would help the hospital staff to decide what
blood he needed as part of his treatment. This simple request
became the start of what has become an international PBM
initiative to increase the involvement and knowledge of
patients and their families, in the laboratory aspects of their
transfusion treatment.
In March 2013 Harvey was admitted through Accident &
Emergency (A&E) at Worthing hospital, where blood tests`
that he had a Haemoglobin of 36 g/L. He was diagnosed with
Acute Leukaemia, subsequently confirmed as Acute Myeloid
Leukaemia, was double Blood Grouped and Antibody
screened and had a Blood Group of AB Rh Positive and no
atypical antibodies present. He was flagged for Irradiated and
Cytomegalovirus (CMV) Negative Blood and Platelets. He was
transfused with Red Cells, Platelets and started Chemotherapy
and Shared Care with The Royal Marsden Hospital (RMH).
Harvey received a Bone Marrow Transplant (BMT), from
his brother Max, who was A Rh Negative, and Harvey
subsequently started grouping as A Rh Negative.
Regretfully Harvey rejected the BMT and succumbed to
Host versus Graft Disease on 6th October 2014, after a 19
month battle. At his Farewell on 30th October 2014, the family
showed a picture of Harvey in the laboratory with Malcolm
Robinson (Chief Biomedical Scientist, Blood Transfusion
WSHT) whilst on his tour as a “Trainee Scientist” for the day.
< 10 Blood and Transplant Matters – June 2015

Consultant Paediatrician, Jon Rabbs informed Malcolm
that they had seven other critically ill youngsters who
wanted to visit the laboratory, as Harvey had so “Harvey’s
Gang” was created.
Led by Malcolm, a small group of people made a
collaborative and creative effort to make the laboratory
tour more memorable for all concerned, including patient,
family, paediatric staff, and all the laboratory staff not just
haematology and blood transfusion.
Ruth O’Donnell Transfusion Practitioner WSHT bought
mini lab coats, Wendy Cottee, Haematology Lead reverse
engineered them to handmake more, Emma Whitmore
designed and printed certificates of attendance and
coined the phrase “Harvey’s Gang” and provided NHS
Blood and Transplant Patient Information Leaflets, comic/
sticker books, and “Ask me who am I” stickers, LabCold
delivered a huge box of penguins, the Serious Hazards of
Transfusion (SHOT) sent boxes of pens, Ortho provided
rulers and highlighter pens, Malcolm bought sweets and
got the trainee scientist badges made, suggested naming
the new WSHT Ortho VISION analyser “Harvey” and
inviting Harvey’s parents into the laboratory, to launch
both machine and initiative, in Harvey’s name.
Ortho Clinical Diagnostic stopped a board meeting to
tell Harvey’s story, and agreed to “name” the first 100
new Blood Grouping analysers, the Ortho VISION, sold
into laboratories. They would support them with Harvey’s
Gang “kits” so that they too could engage their patients
in their laboratories, this includes providing memorial
plaques to accompany those machines, and sending the
stories of the laboratories and patients to WSHT to add to
their records. Harvey’s Gang is now international and so
far it has reached Japan. There has been media attention,
newspaper, radio and television coverage and Harvey’s
Gang continues to grow at WSHT and in the South East
Coast region as other Trusts adopt this PBM initiative.
Since then William, age four who has an inoperable
Brain tumour has joined Harvey’s Gang, and Ellae Mae a six
year old with Chemotherapy treated Acute Lymphoblastic
Leukaemia visited, on her last day, hopefully, of
Chemotherapy. Regan a ten year old, second stage WILMS
tumour visited and Francesca an eight year old little girl
with Fanconi Anaemia visited the laboratory on the same
days as Ian Trenholm, Chief Executive NHSBT and Huw
Williams Director of Diagnostic and Therapeutic Services
NHSBT, to see this powerful PBM initiative in action.
All the children have photographs taken in the
laboratories and this is added to a history sheet which is
kept as part of the record of attendance.
Harvey’s parents officially launch Harvey’s Gang
Back L-R: Emma Whitmore Patient Blood Management
Practitioner NHSBT, Malcolm Robinson WSHT, Jon Rabbs
Consultant Paediatrician WSHT, Melanie Holtom Ortho Clinical
Diagnostics.
Front row Claire and Richard Baldwin with the memorial
photograph of Harvey that hangs in the laboratory next to the
machine that bears his name.
They get a copy of their photo, their certificates of
attendance and “goody bags” given to them.
Blood and Transplant Matters – June 2015 11 >

Work continues on refining the blueprint of the packs
so that others can simply pick it up and implement it in
their own Trusts, and applications for grants and funding
to ensure that this initiative can be supported as it grows,
are underway.
On the donor side, NHSBT is looking to engage donors
with Harvey’s Gang and tell donors stories in their local
donation centres and sites, along with patient stories from
regional hospitals to show where and how donated blood
and blood components really do help to save and improve
lives every day.
Morale in the laboratory has soared to new heights and
as one Biomedical Scientist said “when it’s a really difficult
day I look at Harvey’s picture and remember why we do
what we do, it helps me refocus and keep going”. The
Laboratory profile has been raised with regular mentions
in the Trust newspaper and in the media which has had a
positive impact. There is a better understanding of the role
the hospital laboratory plays in daily patient care.
Emma Whitmore
Patient Blood Management Practitioner
NHSBT, Tooting
Email: emma.whitmore@nhsbt.nhs.uk
Malcolm Robinson
Chief Biomedical Scientist, Blood Transfusion,
Western Sussex NHS Hospitals Foundation Trust
Email: malcolm.robinson@wsht.nhs.uk
Involving, Informing and Consenting Patients Receiving Red Cell Transfusion
Between January and April 2014, the National
Comparative Audit of Blood Transfusion collected
information from 2,784 sets of patient casenotes in 164
hospitals in the UK, and 2,243 patients from 162 hospitals
completed a patient survey. This is the largest survey
ever undertaken in the UK and was commissioned by
the Advisory Committee on the Safety of Blood, Tissues
and Organs (SaBTO). All patients had received a red cell
transfusion.
The purpose of the audit was to assess the extent to
which patients are involved in the decision to transfuse
them, how well informed they are and how well care
records demonstrates the information and consent process.
How Many Patients are Involved in Transfusion
Decisions?
Involvement in decision making is different from being
given written information or having things explained.
Delivering person-centred care means recognising that the
patient is a person who has a voice and the right to express
an opinion, not someone whose role is to passively receive
care offered. Table 1 shows how many patients thought
they were involved.
Involved with the decision
N = 2,243
making
% N
Yes 56 1,252
To a certain degree 18 407
No 21 462
Cannot remember 5 120
Not stated 0.1 2
The majority felt they were, yet just over one fifth of
respondents explicitly felt they had not been involved.
How Many Patients Were Given Information About
Transfusion?
Being given information includes being provided with a
leaflet or other written matter and/or having transfusion
explained by a healthcare professional. This was measured
in three ways: whether it is Trust policy to provide
information: whether there is a note in care records that
information had been provided and whether the patient
recalled is being given information. Auditing this was not
straightforward because information and explanation can
be given to a patient at several points along the patient’s
journey through the healthcare system, so patients saying
they had none, might have had some previously but, it is
safe to assume that if they did, then for those answering
“no”, that information made little impact.
93% (131 of 141 sites) of Trusts have a policy which
requires staff to inform patients about risks, benefits
and alternatives, but only 77% of these, routinely give
information to patients.
Perhaps it is surprising that not every Trust considers
that patients should be told about transfusion. In trying
to gauge the extent to which information is given, we
audited the patients’ care records and surveyed patients.
Of 2,782 records audited, the provision of information was
documented for 19% (519), not documented for 77%
(2,133) and not stated for 5% (130). By contrast the table
below shows what we found when we asked patients:
< 12 Blood and Transplant Matters – June 2015

National
Were you given information? % N
Yes 28 631
No 62 1,389
Cannot remember 9 210
Not stated 0.6 13
So there is a discrepancy between what the notes say,
and what the patient recalls. This suggests that what the
Trust considers as being an adequate means of providing
information, may not be as effective as they hope.
Besides providing information, it is important that
patients are aware of why they are being offered a
transfusion and what the benefits and risks of that
transfusion might be. In addition, patients should also be
told if there are any alternatives to transfusion but, it is
worth bearing in mind that for some patients, there is no
satisfactory alternative. We already know that the majority
of Trusts require staff to have this discussion, but what
do the records say? Documentation that this was done
was found in 23% (629) of notes, not documented for
73% (2,043) and not stated 4%. When the patients were
surveyed, this is what we found:
National
Benefits of Transfusion Explained % N
Yes 68 1,534
No 19 434
Cannot remember 11 242
Not stated 1 33
National
Risks of Transfusion Explained % N
Yes 38 858
No 44 998
Cannot remember 15 343
Not stated 2 44
National
Alteratives Offered
% N
Yes 8 184
No 76 1,714
Cannot remember 12 280
Not stated 3 65
Again, there seems to be a discrepancy between what
the notes say and what the patient recalls.
Consent
While there is a general legal and ethical principle that
patient consent should be obtained prior to a medical
intervention, SaBTO have issued recommendations reenforcing
the need for valid consent for blood transfusion
to be obtained and documented in the patient’s clinical
record by the healthcare professional. 85% (120 out of
141 sites) had a policy on consent for transfusion, and
in the notes consent was documented for 43% (1192),
not documented for 57% (1588), not stated for four. If
consent was not documented, there was a note in only 4%
of casenotes that the patient was unable to give consent.
This is what the patients said:
Were you asked to give consent
National
for transfusion
% N
Yes 59 1,333
No 23 508
Cannot remember 16 361
Not stated 2 41
Conclusion
Obtaining valid consent is an implicit part of good
patient care in relation to transfusion practice. The
SaBTO recommendations on patient information and
consent for transfusion are explicitly clear with detailed
recommendations.
This audit, while perceived to be challenging, did a
have good level of participation enabling us to comment
on current UK practice and make recommendations
for change. While Trusts overall have policies in place
covering key principles, actual practice does not reflect
this as shown from the documentation within notes
and the feedback from patients and staff. The need to
document the indication for transfusion, should be an
absolute minimum requirement within hospitals, with the
explicit need to communicate this indication to patients
supported by discussion of risks, benefits and alternatives.
The majority of prescribers currently are junior doctors
and, there is an urgent need to strengthen their training
not only in relation to obtaining patient consent but, also,
appropriate prescribing. There is a need to strengthen
the content of training curricula and, also, the delivery
of education. Strategies to increase the uptake and use
of eLearning modules to support training, needs to be
reviewed, with perhaps incorporation into other types of
learning, including face to face sessions rather, than as just
a stand-alone option.
The audit demonstrates a major discordance between
hospital policies and actual practice in particular, around
the provision of written information to patients. The
development and dissemination of such information,
should now be reviewed. Consideration should be given
to the incorporation of transfusion information within
Blood and Transplant Matters – June 2015 13 >

leaflets on relevant specific conditions given to patients to
help streamline the provision of information with greater
exploration of information technology, to increase patient
and health care access.
Overall, the audit highlights the need for a more
standardised and structured approach to the process of
providing information and, obtaining patient consent, with
emphasis on appropriate documentation.
John Grant-Casey
National Comparative Audit Manager
NHSBT, John Radcliffe Hospital
Oxford
Email: john.grant-casey@nhsbt.nhs.uk
Shubha Allard
Consultant Haematologists
NHSBT, Colindale
Email: shubha.allard@nhsbt.nhs.uk
Remote Allocation of Platelets
“Necessity is the mother of invention”. This is something
we learn early in our scientific careers. However, it’s not
until you encounter this necessity and, develop an idea
born from this necessity, that you really understand and
appreciated the beauty of this proverb. The necessity was
to reduce the distance of platelets from our users and
the invention, was remote release of platelets! This is our
story…
Glan Clwyd District General Hospital is situated in
beautiful North Wales and is currently undergoing a huge
renovation to remove asbestos from the older parts of
the building. Part of the renovation, was to build a ‘fit for
purpose’ Emergency Quadrant, complete with attached
theatres and Intensive Therapy Unit (ITU).
As a result of this work, a decision was made to relocate
all of Pathology to a purpose built facility out on the back
field, to make way for the improved ITU department. We
didn’t mind the move as the new building was designed
with our service in mind and, has fantastic views of
rolling countryside. However, it became evident that we
were soon missed by our users – particularly as our old
laboratory was very centrally located in the middle of the
hospital and provided rapid access to blood products, in
emergency cases.
We had previously installed two remote-release fridges
in the hospital, allowing remote release of red cells and,
these had been working well for us for some time. An
army of staff had been trained and, were ‘at the ready’
to collect blood for transfusion. The general opinion of
the staff that we had trained, was they liked the ease and
flexibility of the system as they were able to determine
patient eligibility for themselves, using a Ward Enquiry
software module and collect the blood at a time that was
convenient to their Patient Care Schedules. The remote
release of blood, has quickly become normal practice in
our hospital, most likely because it’s a very user-friendly
system.
Our main users at the Cancer Centre quickly became
familiar with our new address, and during the colder,
darker, wetter days (we are in Wales of course!) were
not too pleased with the new neighbourhood or the
views and as we issue over 125 units of platelets a year
we knew there would be trouble ahead! We were soon
contacted regarding the changes and during a meeting
with the Cancer Centre Matron, it became apparent
that the laboratory being away from the main hospital,
meant that staff had less time with their patients to deliver
the care that they needed. Patients were waiting longer
for platelets, staff were becoming displeased with the
implications of collecting the platelets from the laboratory
and the 30 minute rule for safe return, was almost
impossible to enforce. Therefore, we occasionally had to
waste platelets. This was the origin of our necessity.
To improve the services we provide to our users, we
decided to work closely with our supplier to find a
solution... if only there was a way of remotely releasing
platelets. We discussed our situation and ideas with them
and, together, came up with a plan!
We installed a Locked Platelet Incubator that was fully
integrated into our Blood Track System just outside of
the Cancer Centre. We used
the Plan, Do, Study and Act
(PDSA) cycle, to work up
the system and develop the
software and process. This
cycle was repeated until we
were completely happy that
we had a robust and safe
system, which was easy to
use when staff were under
pressure. Once we got to this
final stage of the development
process, we finally validated
the new system.
< 14 Blood and Transplant Matters – June 2015

We were also keen to reduce our wastage and to keep
it at a minimum, by working with our supplier, we found
a way to remotely allocate ABO compatible platelets from
the comfort of our new laboratory. After considering many
factors and changes, we now have a fully- functional
Remote Platelet Incubator, complete with full vein-to-vein
traceability. Our traceability is recorded, using a ward fating
module. The module works alongside the blood tracking
system and allows users to record the arrival of the blood
or product onto the ward and also to fate the unit once it
has been transfused. This method of fating blood has been
very successful in reducing the amount of time we spend
on traceability whilst maintaining our compliance levels.
Remote allocation and release of platelets has been
live in our hospital since January and has been gaining
popularity with the ward staff as it saves them a lot of time
that can be better spent with their patients. Because of the
positive feedback we have had from our users, we intend
to roll out the training to the rest of the hospital, starting
with our highest users as priority.
After the successful roll out of our Remote Allocation of
Platelets Project, we have completed some further work to
develop software, that allows us to remotely allocate ABO
compatible red cells to patients too. This is really helpful
in ensuring patients receive compatible blood quickly in
an emergency and, also, helps keep blood wastage to a
minimum. We, also, remotely allocate batched products
such as anti-D prophylaxis, albumin and prothrombin
complex concentrate.
All these changes have had a positive impact on the
running of our hospital, and ensure enhanced patient care,
promoting good working relationships with the ward staff.
We would very much like to thank our colleagues in the
Cancer Centre for their patience whilst we developed this
novel system, and for agreeing to partially fund the project.
Glossary:
Blood Track: Is an electronic system used to track all
blood product transactions. This system can also monitor
temperatures of all integrated locations; keeps track of
stock count; records staff training; allows full traceability
and alerts the laboratory staff to any problems that occur
and the users involved.
Blood Track enquiry: This is a ward function of blood
track, which allows all trained users to determine patient
eligibility for Electronic Issue (E.I.). If their patient is eligible
it will allow the users to see all locations where they can
find compatible blood. This function also displays patient
blood type and allows users to print off a pick up slip to
allow collection from the refrigerators.
Blood Track-Ward fating: This is a function that supports
our vein-to-vein traceability. As soon as a blood product
arrives on the ward, the user can “arrive” the unit on
the blood Track System and then “end transfusion” once
transfusion of the product is complete.
Emma Copperwaite
Specialist Biomedical Scientist
Glan Clwyd Hospital, Betsi Cadwaladr University
Health Board (BCHU)
Email: emma.copperwaite@wales.nhs.uk
Implementation Team (in photo l-r) Steve Ramsey, Emma Copperwaite and Nicola Polley
Blood and Transplant Matters – June 2015 15 >

Audit of Antenatal Immunisation with K
Background
Anti-K is an antibody directed against the K antigen
of the Kell Blood system which has been reported to
cause severe extravascular and, occasionally, intravascular
haemolysis. Anti-K can be developed in K negative men
and women as a result of exposure to the K antigen
through a transfusion of K positive blood, pregnancy or
transplantation. The literature suggests anti-K is more likely
to be caused by previous transfusion, than as a result of
the other known exposures (Lee E and de Silva M, 2004.)
Therefore, to reduce the incidence of the development of
anti-K in women of, or younger than, child-bearing age,
must be avoided during transfusion by providing K negative
blood. This has been established practice since before the
British Committee for Standards in Haematology (BCSH)
guidelines in 2006 formally identified it as a requirement.
This audit was undertaken to assess the effectiveness
of measures to avoid transfusion of K positive blood to K
negative women, and so reduce the incidence of anti-K
in women thus determining compliance with the current
BCSH guidelines that recommend this practice.
Audit Design
The aim of this audit is to ensure that restrictions
surrounding transfusion of K+ blood to women of, or
prior to, child-bearing age from the relevant guidelines
and policies were applied consistently and that NHS Blood
and Transplant (NHSBT) provides components and advice
appropriately in these cases.
Two Objectives Were Established:
1. To ensure we provide expert quality of advice to all
hospitals regarding the use of K negative units in
women of child-bearing age (51 years or less).
2. To provide assurance that our provision of K negative
units for hospitals is accurate and appropriate, ensuring
that there is always an adequate stock available, to
reduce the potential of having to use K positive blood
components.
It was decided to use two large referral centres for Foetal
Medicine; the Bristol Royal Infirmary (BRI) and the John
Radcliffe Hospital (JR), Oxford. The data was collected
retrospectively, using a short proforma.
The cases of Anti-K were identified from historical
records covering the previous three years. Dr Mamta
Chudasama, (SpR) and Professor David Roberts,
(Consultant Haematologist) in collaboration with the
Laboratory Manager and staff at the JR, completed the
proformas to provide the information regarding their
antenatal patients with anti-K. The authors, in collaboration
with the Laboratory Manager and the Clinical Audit and
Effectiveness Team at the BRI completed the same process
for cases from the South West.
The data collection, took into consideration the
transfusion history of these women; the number, ABO
and K phenotype of units transfused at each transfusion
episode where records were available. The ABO, Rh and
K type of both the mother and father of the sample in
question was also collected from existing records where
available.
The results were measured against the 2012 BCSH
compatibility guidelines pertaining to the use of K negative
blood for women of child-bearing age, and reviewed by
the Audit Team.
Figure 2: Audit Criterion and possible outcome
classifications.
Criterion
No females
below age 51
to be given K
positive products
Expected Level
of Performance
100%
Exceptions
Emergency
transfusion
where a K
negative product
is unavailable
It was then determined whether the sensitisation
was due to transfusion of K positive blood and the
likelihood of such an event was classified as:
Probable – K positive blood transfused and father
K negative
Possible – K positive blood transfused and father
K positive
Unlikely – K negative blood transfused or no
transfusion and father K positive
Uncertain – Transfusion history uncertain
< 16 Blood and Transplant Matters – June 2015

Key Findings
Table 1: Performance Level.
Criterion
Expected Level
of Performance
Actual Level of
Performance
No females
below age 51
to be given K
100% 100%
positive products
• In no cases was transfusion of K positive blood identified
as the definite cause of K alloimmunisation.
• In seven cases, K alloimmunisation by the transfusion of
K positive blood was deemed unlikely, as there was no
recorded history of transfusion with K positive blood.
• There were two cases where K alloimmunisation by the
transfusion of K positive blood was uncertain. In both
cases, there is no direct evidence to implicate transfusion
as a cause of alloimmunisation and, other possibilities
were evident.
• In four cases, K alloimmunisation by the transfusion of
K positive blood was probable or possible in transfusion
that took place before 2006, when the first BCSH
guidelines for this issue were introduced. There were no
records of any units being transfused to these patients
during the last 15 years and certainly none since 2006
when the current BCSH guidelines, that formally stipulate
the need to avoid transfusion of K positive blood to K
negative women of childbearing age, came into place.
Table 2: The Transfusion History and Paternal K Phenotype of K Alloimmunised Women
Case Number Transfusion Date of
Transfusion
K Phenotype of
Transfusion
Paternal K
Phenotypes
Outcome (Fig 2)
JR 1 No None N/A NK Unlikely
JR 2 No None N/A NK Unlikely
JR 3 Yes 2013 K neg NK Unlikely
JR 4 Yes 1998 NK NK Possible
JR 5 Yes 1992 NK NK Possible
JR 6 Yes pre 1992 NK K neg Probable
JR 7 Yes 1997 NK K neg Probable
JR 8 No None N/A NK Unlikely
JR 9 No None N/A NK Unlikely
BR 1 No None N/A K pos Unlikely
BR 2 Yes 2009 at North Not known K pos Uncertain
Devon
BR 3 No None N/A K pos Unlikely
BR 4 No None N/A K neg Uncertain
Conclusion
The evidence suggests that no women have been
alloimmunised by the transfusion of K positive blood at the
JR or the BRI since 2006, when the current BCSH guidelines
were implemented. In view of the positive findings, it was
recommended that this audit need not be repeated at the
BRI or JR until the 2016/17 NHSBT Clinical Audit Programme
with consideration being given to employing a prospective
audit, examining contemporaneous cases. However, similar
studies to review cases at other hospitals, would provide a
wider view and, we would be happy to share the audit tool
to assist with any such undertakings.
The findings of this clinical audit were shared and discussed
with the Reference Service Manager, NHSBT Filton, the
Head of Blood Bank, BRI and the Head of Blood Bank,
JR. These findings were also shared with the Regional
Transfusion Committees, for further dissemination to
regional hospital blood banks.
Dawn Tilsley
Senior Clinical Audit Facilitator
NHSBT, Filton, Bristol
Email: dawn.tilsley@nhsbt.nhs.uk
Sara Wright
Consultant Clinical Scientist Trainee
NHSBT, Filton, Bristol
Email: sara.wright@nhsbt.nhs.uk
References:
BCSH guidelines as follows: http://www.bcshguidelines.
com/documents/Compat_Guideline_for_submission_to_
TTF_011012.pdf
http://www.bcshguidelines.com/documents/BCSH_
FMH_summary_sept2009.pdf
BCSH Guidelines for Blood Grouping and Antibody
Testing in Pregnancy 2006 Gooch A, et al Lee, E.,
de Silva, M. (2004) Transfusion, 44 9S 104A.
Blood and Transplant Matters – June 2015 17 >

National Comparative Audit of Anti-D Immunoglobulin Prophylaxis
The introduction of anti-D prophylaxis for RhD negative
women in the late 1960s resulted in a dramatic reduction
of haemolytic disease of the fetus and newborn, due to
immune anti-D. Most healthcare workers involved with the
care of pregnant women, or the provision of laboratory
services to support Maternity Units, will never have seen
the devastating effects of this condition on women and
their families. The interventions include Post-delivery (PD)
prophylaxis for women delivering RhD positive babies,
prophylaxis for potentially sensitising events (PSE) during
pregnancy and routine antenatal anti-D prophylaxis
(RAADP) in the third trimester given to all RhD negative
women to prevent sensitisation as a result of silent
fetomaternal haemorrhage (FMH).
The 2013 National Comparative Audit (NCA) of anti-D
immunoglobulin (Ig) prophylaxis looked at RhD negative
women across the whole pathway from booking to
delivery – it did not include women who had terminations
of pregnancy or early miscarriages. The audit standards
were taken from the British Committee for Standards in
Haematology (BCSH) and the Royal College of Obstetricians
and Gynaecologists (RCOG) anti-D guidelines and the
National Institute for Health and Care Excellence (NICE)
technology appraisal on RAADP.
Midwives and transfusion staff in 153 UK hospitals with
Maternity Units worked together to audit laboratory and
maternity records on nearly 6000 RhD negative women
booking in September 2012 for delivery in Spring 2013.
Overall, the audit showed effective delivery of anti-D Ig
prophylaxis.
There are two recommended RAADP regimes – a single
1500 IU anti-D Ig injection at 28-30 weeks gestation, used
by 94% of participating sites, and a two-dose regime
of at least 500 IU given at 28 and 34 weeks, which is as
effective but less popular. 99% of eligible RhD negative
pregnant women, received at least one anti-D Ig injection
although full compliance (right dose at the right time) with
the single dose regime was better compared to the twodose
regime (90% vs.59%).
Post-delivery prophylaxis was given to 98.4% of RhD
negative women delivering RhD positive babies and,
91.6% had the right dose at the right time. It is important
for a Kleihauer test to be taken from the mother, shortly
after delivery to check if sufficient anti-D Ig has been given
to cover any fetomaternal haemorrhage (FMH) at birth,
and 97% had such a test. The volume of FMH (fetal red
cells) was 2mL or less in 88% and in 97% the estimated
FMH was 4mL or less. A ‘standard’ 500 IU post-delivery
anti-D Ig dose will cover a 4mL FMH and 1500 IU will cover
12mL therefore, additional anti-D Ig was required, where
the standard dose of anti-D Ig was insufficient to cover the
estimated FMH. Only 0.5% of women needed additional
anti-D Ig to prevent sensitisation.
The strategy to audit maternity and laboratory records,
resulted in a good overview of the anti-D Ig given to cover
potentially sensitising events in pregnancy, even though
this made analysis of the audit data complex and timeconsuming.
The commonest PSE requiring anti-D Ig, was
antepartum haemorrhage (42%) followed by miscarriage
and stillbirth (26%) and falls or trauma (19%) with
procedures such as amniocentesis, chorionic villus sampling
and other in-utero procedures. Anti-D Ig was given to
95.8% of the documented PSEs. It was sometimes difficult
to establish the timing of the PSE, so approximately 79%
had the injection at the right time but, 96% received the
correct dose of anti-D Ig for gestation.
NICE recommend that women give consent to receive
RAADP and, it is good practice to counsel RhD negative
women about the risks of sensitisation, using written
patient information to supplement this. However, only
a third of women were documented as having been
given information and, only 57% of women had consent
documented in their maternity notes.
Continuity of care is important when delivering a
complex preventative regime such as anti-D Ig prophylaxis,
particularly as there are a number of different professional
groups involved. It is important to take the choice of the
woman herself into account. The audit showed good
compliance with anti-D Ig prophylaxis and there were very
few women put at risk of sensitisation. However, it was
notable that where women moved from one organisation
to another during their antenatal care, or were discharged
early following delivery, it was not possible to be sure that
appropriate prophylaxis had been given.
There are areas for improvement, and it is recommended
that local policies are reviewed, particularly as the new
BCSH anti-D Ig guidelines have recently been published 1 .
There are many educational resources available for clinical
and laboratory staff (see LearnBloodTransfusion 2 and the
Serious Hazards of Transfusion scheme 3 ) and excellent
patient information leaflets accessible on the NHSBT 4 and
other Blood Service websites.
As with all National Comparative Audits our thanks go
to those who participated! The full audit report can be
found on the NCA homepage 5 .
< 18 Blood and Transplant Matters – June 2015

Dr Megan Rowley
Consultant in Haematology and
Transfusion Medicine
NHSBT, Colindale and Imperial College Healthcare
NHS Trust
Email: megan.rowley@nhsbt.nhs.uk
References:
1
BCSH guideline for the use of anti-D immunoglobulin
for the prevention of haemolytic disease of the fetus
and newborn H. Qureshi et al Transfusion Medicine,
2014, 24, 8-20
2
http://www.learnbloodtransfusion.org.uk
3
http://www.shotuk.org
4
http://hospital.blood.co.uk
5
http://hospital.blood.co.uk/audits/national-comparativeaudit
The Introduction of a Regional Road Map to Improve Access to Therapeutic
Apheresis Services in the North West of England and North Wales
Introduction
Apheresis is a commonly-employed method for the
removal of harmful substances and proteins such as
antibodies, that drive various disease processes. Different
types of therapeutic apheresis modalities exist, such as
plasma exchange, leucodepletion, red cell exchange and
extracorporeal photopheresis. All therapeutic apheresis (TA)
procedures require the use of specially designed machines
operated by experienced healthcare clinicians. The medical
conditions requiring TA are often unpredictable, severe
and frequently require specialist medical and critical care,
as well as access to the apheresis procedure itself. Some
specialities, such as renal medicine, are regular users
of the service, whilst others, such as dermatology and
neurology, may have a less frequent need, due to the
rarity of diseases. Emergency presentations of medical
conditions, such as thrombotic thrombocytopenic purpura
(TTP), require prompt urgent assessment of the patient,
with rapid diagnosis and commencement of treatment,
including TA, to prevent fatalities (BCSH guidelines).
Historically, within the North West of England (NWoE)
and North Wales (NW), there was an absence of a
standardised referral pathway, for the management of
patients requiring therapeutic apheresis (TA). Service
delivery was very variable, with some organisations having
a comprehensive seven day service either in-house or
outsourced with others having a fractured pathway, for
the management of patients requiring urgent intervention.
This practice was intensified in emergency situations, such
as TTP, where delivery of TA is time- critical.
Nationally, variability of service delivery models continues
to dominate in practice, often with little collaboration
between the different specialities that utilise TA. Whilst
variability exists in the utilisation of in-house services,
others contract the expertise of external organisations,
such as NHS Blood and Transplant (NHSBT). Good practice
is evident in the UK as demonstrated by the large TTP
centre at University College London Hospital who accept
regional and national referrals for patients with a new
diagnosis of TTP, offering a comprehensive service including
the diagnostic workup. However, regionally as well as
nationally, there remains an absence of comprehensive
multi-disciplinary multi speciality services.
As a joint collaborative between the North West Regional
Transfusion Committee and NHSBT, a small project team
reviewed the current service availability of TA within the
NWoE and NW. The findings from a questionnaire survey
revealed a lack of clarity about referral pathways for TA
with some organisations unable to access a robust service
for patients, leading to patient safety concerns.
Method
A retrospective questionnaire (Survey Monkey) was
circulated via email to named clinicians in haematology,
renal medicine, dermatology, neurology, cardiology,
rheumatology, immunology, endocrine (lipidology) and
paediatrics at all hospitals in the NWoE and NW. The
questionnaire aimed to identify the regional experiences
of TA and highlight any challenges encountered over a
12 months period. Due to poor initial response, a letter
outlining the rationale behind the project was sent to
Chief Operating Officers of the organisations surveyed,
inviting them to encourage completion of the electronic
questionnaire by the relevant departments; this was
followed simultaneously with a paper questionnaire
(with a return envelope) to all non-responders.
Although this yielded an additional response, the overall
Blood and Transplant Matters – June 2015 19 >

esponse rate was still poor and, as a result, targeted
phone questionnaires were conducted to achieve 100%
from response from all haematologists in the region.
Haematology was singled out, as it was felt they were
most likely to have the most insight of the Trusts use of
TA services. The data obtained, was entered into an Excel ©
spreadsheet and analysed internally by a data analyst.
Figure 2: Apheresis Providers for Plasma Exchange in
Haematology across North West of England and North
Wales (number = 25 ).
Apheresis Providers for Plasma Exchange
in Haematology
Further intelligence into the regional challenges in
accessing TA was obtained via a multi-speciality focus
group meeting with Lead Clinicians, Service Users and
Managers. This was followed by a one day educational
symposium on TA delivered by national experts in the field.
The audience was comprised of local service users from
different specialities who shared the common challenges in
access to TA. Feedback demonstrated the regional appetite
for uniformity of practice and standardisation of care.
Results
10, 40%
4, 16%
5, 20%
6, 24%
Responses were analysed from Haematologists,
Nephrologists, Rheumatologists, Neurologists and
Lipidologists in 27 Trusts from across NWoE and NW.
There was at least one response from 23 of the Trusts;
57 respondents in total. Cardiology and Dermatology data
was not inputted, as it was felt they did not require the use
of emergency TA; Paediatric data will be analysed at a later
date separately.
Figure 1: Number of clinicians who reported difficulties
gaining access to TA (number = 57).
Difficulty Accessing Apheresis Service?
1, 2%
% NHSBT % In House % Refer out % No response
The findings of the survey highlighted the absence of
uniformity in access to TA. Lack of clarity and variability in
access to TA in the NWoE and NW was evident in all the
responses. Over 50% of respondents reported absence
of a contingency plan if a patient was admitted requiring
TA, with over 44% (number = 25) reporting difficulties in
gaining access to TA in an emergency (Figure 1). Further
variability arose with regards to the delivery of the TA with
some service users reporting an in-house service (number
= 6, 24%) whilst other referred to outside organisations
(Figure 2). This not only highlights patient safety concerns
but also the unnecessary stress and work related pressures
that can face clinicians during an emergency clinical scenario.
31, 54%
% Yes % No %Blank
25, 44%
Regional Apheresis Map
It was recognised early that TA provision could be
improved by the establishment of regional services, where
several hospitals are served by a single service provider. This
was anticipated to provide robust access for management
of the peaks in referrals and, to provide for flexibility for
clinicians to access a service 24/7. In collaboration with
Renal Physicians, Haematologists in the region and NHSBT,
a regional apheresis roadmap was launched in 2014. The
roadmap provides clarity regarding access to TA services
for every Trust in the region. In parallel, centralisation of
some clinical services such as TTP, has led to clarity and
delivery of safer health care. Evaluation of the service will
take place, to ensure it is resourced sufficiently in order
to have the flexibility and responsiveness required to treat
patients who need urgent access to treatment.
< 20 Blood and Transplant Matters – June 2015

Figure 3: Diagrammatic Representation of Regional Apheresis Road Map for NWoE and NW (service user clicks on the
Trust name which reveals a page that explains the referral pathways for the different conditions requiring TA).
13
12
ISLE OF MAN
NORTH WALES
DURHAM
CUMBRIA
26
YORKSHIRE
3 8 LANCASHIRE
7
19
29
16 15
18 22
10
4
9
24 20 25 23 21
17
27
28
1 2
6
5 CHESHIRE
11
14
1 Aintree University Hospitals NHS Foundation Trust
2 Alder Hey Children'S NHS Foundation Trust
3 Blackpool, Fylde and Wyre Hospitals NHS
Foundation Trust
4 Central Manchester University Hospitals NHS
Foundation Trust
5 Countess of Chester Hospital NHS Foundation Trust
6 East Cheshire NHS Trust
7 East Lancashire Hospitals NHS Trust
8 Lancashire Teaching Hospitals NHS Foundation Trust
9 Liverpool Heart and Chest NHS Foundation Trust
10 Liverpool Women'S NHS Foundation Trust
11 Mid Cheshire Hospitals NHS Foundation Trust
12 Noble'S Isle Of Man Hospital
13 North Cumbria University Hospitals NHS Trust
14 North Wales: Betsi Cadwaladr University Health
Board
15 Pennine Acute Hospitals NHS Foundation Trust
16 Royal Bolton Hospital NHS Foundation Trust
17 Royal Liverpool and Broadgreen University Hospitals
NHS Trust
18 Salford Royal NHS Foundation Trust
19 Southport and Ormskirk Hospital NHS Trust
20 St Helens and Knowsley Hospitals NHS Trust
21 Stockport NHS Foundation Trust
22 Tameside Hospital NHS Foundation Trust
23 The Christie NHS Foundation Trust
24 The Walton Centre NHS Foundation Trust
25 University Hospital of South Manchester NHS
Foundation Trust
26 University Hospitals of Morecambe Bay NHS Trust
27 Warrington and Halton Hospitals NHS Foundation
Trust
28 Wirral University Teaching Hospitals NHS Trust
29 Wrightington, Wigan and Leigh NHS Foundation
Trust
Conclusion:
The introduction of the regional apheresis map in the
NWoE and NW has been a two year project that has
required the buy in of stakeholders from different specialties
to ensure the introduction of a uniform approach to TA. It
is a ‘live’ document and it is anticipated it will undergo
further developments as lessons are learned. It is hoped
Dr Samah Alimam
Haematology Registrar, North Western Deanery
Email: samah.alimam@nhs.net
Ms Hannah Scrimshaw
Administration Manager, Therapeutic Apheresis
Services
NHSBT, Birmingham
Email: hannah.scrimshaw@nhsbt.nhs.uk
Dr Shruthi Narayan
Haematology Specialist Registrar
North Western Deanery
Email: shruthishive@hotmail.com
that this project would serve as a model for other regions
of the UK, where similar issues are likely to exist.
The regional apheresis map can be accessed via:
http://hospital.blood.co.uk/patient-services/therapeuticapheresis-services/how-to-make-patient-referrals-to-tas/
referrals-in-the-north-west-of-england-and-north-wales/
Ms Catherine Howell
Chief Nurse – Diagnostic & Therapeutic Services
NHSBT, Filton
Bristol
Email: catherine.howell@nhsbt.nhs.uk
Dr Kate Pendry
Consultant Haematologist and Clinical Director
for Patient Blood Management
NHSBT, Manchester
Email: kate.pendry@nhsbt.nhs.uk
Blood and Transplant Matters – June 2015 21 >

Case Study
I first became aware
that I was unwell back
in 2008 when, after a
bad chest infection,
my breathing became
laboured. Little things
at first, like bending to
pick things off the floor
or stretching to put
washing on the line.
My GP couldn’t find
anything wrong, but as
time went by and my
breathing was getting
worse, I was sent to
May 2013
the local hospital for
various tests including x-rays and bloods.
celebrating the New Year the previous night and would
have been unsafe to drive. I, being my father’s daughter,
refused to pay double fare for a taxi on New Year’s Day –
so I ended up driving myself with Colin as a passenger to
the hospital. The surgery took 13 hours and it wasn’t all
plain sailing, there were a few blips but the medical team
were fantastic. My surgeon explained afterwards that they
had underestimated just how poorly I was and if I had
not received the transplant when I did, I would probably
not have survived very much longer. Perfect timing and
an amazing gift from my donor and family, strangers to
whom I will be forever grateful and pray for daily.
However none of the tests detected a problem and my
breathlessness was put down to anxiety and age – I was
45 at the time and have never been an anxious person, so
I wasn’t totally convinced by this explanation. Eventually
after several more chest infections, a greater decline with
my breathing and many hospital visits and tests, I was
diagnosed with Idiopathic Pulmonary Fibrosis (IPF) in April
2012. I had never heard of the disease and was initially told
to search the internet for more information.
IPF is a condition in which scarring is produced on
the lungs, in my case for no apparent reason, which
causes the lungs to harden and over time decreases the
capacity for oxygen. There is currently no known cure
and life expectancy is 2.5-5 years. It was explained to
me that my only medical hope would be a double lung
transplant and I was put on the transplant waiting list,
after undergoing all the assessments, in March 2013.
My life changed dramatically during this time. I used to
be very active raising a family (two boys Lewis now 21
and Luke now 18) with my husband Colin, working parttime
as a library assistant, as an Authorised Lay Minister
in my local Anglican Church, walking approx five miles
daily with our dog and so forth, but with the illness I was
on oxygen 24/7 and at times needed a wheelchair to go
out. Everything I knew and did stopped, all my hopes and
dreams for the future, I felt, were stolen from me and I
became totally reliant on other people to help me to do
simple tasks such as washing, dressing, cooking. I hated
it. I tried hard to stay positive and usually succeeded but
some days it was very hard, frightening and overwhelming
and as time went on and I still hadn’t received a call from
the hospital I would sometimes doubt that the call would
come. But the call did come at 5.20 am on New Year’s Day
2014 and threw all our carefully made plans into disarray.
Everybody we knew who were on stand-by to take me to
the hospital – Colin, our sons, family, friends had all been
Family Photographs June 2014
I am now ten months post-transplant and everything
seems to be going to plan and the hospital are pleased
with my progress. Before my operation, when thinking
about the future I assumed life would go back to normal
after transplant, but realise now that things can never be
the same again and we, as a family are building a new
‘normal’.
September 2014
< 22 Blood and Transplant Matters – June 2015

Organ donation is so dear to my heart, it saved my life,
how can it not be? There are people out there praying for
their phone call, for their second chance at life. By going on
the Organ Donation Register we all have the opportunity
to be the answer to someone’s prayer. Incredible!
Joyce Herdson
Haemoglobinopathies and Genotyping
Patients with haemoglobinopathies are amongst the
most highly transfused patient populations over a lifetime.
Patients with transfusion dependent thalassaemia will
often receive two units every three weeks by ten years
old, having started in infancy. For patients with Sickle Cell
disease (SCD) the convention is to maintain the HbA > 70%
to prevent complications in those who are on a long term
transfusion programme. To achieve this, blood can either
be given as a ‘top up’ or as an exchange. The exchanges
can be manual or automated, the latter using an apheresis
machine. A typical example of donor exposure may be a
patient with SCD on an automated exchange programme
who would have ten units every six weeks, equalling
87 units per annum and a patient with thalassaemia
receiving two units every three weeks, equalling 35 units
per annum. Heavy donor exposure, particularly in those
sporadically transfused, is recognised to cause formation
of multiple alloantibodies, thus complicating the provision
of compatible blood (Chou, et al 2012). For haemoglobin
disorders and especially Sickle Cell disease, the ethnicity
and Rh types of the donor population often differ from the
patient population, especially in countries where patients
are most likely to be on regular transfusion and, therefore, be
the most exposed to unfamiliar donor antigens (Singer, et al
2000). Even in populations with similar red cell phenotypes
in donors and recipients, there is a high rate of Rh and Kell
alloimmunisation (Elhence, et al 2014) Therefore, guidelines
for the transfusion of both sickle and thalassaemia patients
recommend matching for full RH and Kell antigens (BCSH
1996), though it is being increasingly recognised that
this is perhaps not sufficient to prevent a significant
proportion of alloimmunisation (Chou, et al 2013). With
the advent of methods for high throughput genotyping,
including Rh variants, to establish the range of major and
minor blood groups for both donors and patients, there
is the possibility of extending the blood group match of
donors and patients from commencement of the patient’s
transfusion life, thus minimising the alloimmunisation risk.
Predicting the cost-benefit or indeed feasibility of this,
however, requires some understanding of the red cell
genotype distribution in the local haemoglobinopathy and
donor population. Such data is limited, and results from
one country cannot readily be extrapolated to another,
because of the different ethnic mix of both donors and
patients in different countries (Matteocci and Pierelli
2014). Another issue regarding alloimmunisation, is that
these are lifetime disorders and patients will move from
site to site. Furthermore, when one calls an ambulance,
the most likely outcome is that they are taken to their
local hospital, whereas their haemoglobin disorder and
thus their transfusions are managed in a specialist centre.
Data from the NHSBT Haemoglobinopathy Survey (not
yet published) shows that only half of transfused patients
have their full red cell phenotype available at their hospital
and that these results are often done locally and, are not
immediately available to other hospitals. Those who have
not had phenotyping performed and who have received
blood in the last three months, will need genotyping
in any case, which is most usually sent away with an
appreciable time lag, thus a patient may need to receive
non Rh and Kell matched blood in extremis. Data from all
studies in alloimmunisation in these disorders show that
patients are most commonly immunised against Rh and
Kell antigens even in countries that have clear guidelines
about matching. Severe transfusion reactions, noted by
Serious Hazards of Transfusion (SHOT) in their chapters
on haemoglobinopathies, note the issue of previously
detectable but, no longer detectable, alloantibodies
causing catastrophic delayed haemolytic transfusion
reactions when patients have attended a different hospital,
to where their original antibody was detected.
Provision of blood for this patient population is predicted
to grow significantly over time due to a number of factors.
Data from the newborn screening programme, shows a
consistent significant number of children being born with
major haemoglobin disorders (Committee 2013); results
of studies of stroke prevention (Adams, et al 1998, Lee,
et al 2006) and the observation that patients are now
living longer with attendant morbidities that increase the
likelihood of the disease severity reaching a threshold for
regular transfusions (Reed and Vichinsky 1999) means that
an increasing number of SCD patients are maintained on
prophylactic transfusion regimens, Another factor is the
current older adult cohort with thalassaemia major, is
shorter in height due to almost universal hyogonadotrophic
Blood and Transplant Matters – June 2015 23 >

hypogonadism and iron deposition in early childhood.
Now that chelators are available from a very early age, one
would expect the current paediatric cohort to be larger
once adults, thus having a larger circulating blood volume.
Genotyping for Patients
Genotyping for patients has now been made available
in RCI laboratories around the country (Birmingham,
Colindale, Filton, Newcastle, Sheffield, Tooting) having
previously been available in IBGRL and are in the process
of completing all stages of validation. This will allow for
a faster turnaround of identification of genotypes in
transfused patients. It is possible to process these samples
out of hours when clinically relevant.
Haemoglobinopathy Genotyping Initiative
(Patients)
NHSBT is undertaking an initiative until the end of June
2016, to provide comprehensive extended genotyping of
haemoglobinopathy patient blood groups including Rh D
and RHCE varients. The ability to identify variants may be
of particular benefit when deciding what blood to give
patients and also permits discernment of Rh allo versus
autoantibodies in transfused patients. These results are
not going to be immediately available, and so in urgent
cases, the testing should be requested through the local
RCI laboratory. Using an advanced genotyping platform,
NHSBT will prospectively genotype as many paediatric
and adult haemoglobinopathy patients as possible at no
cost to the hospitals. Results will be held on Hematos (the
system used by Specialist Services across NHSBT for the
collection and management of data relating to the many
different areas of testing that are carried out under the
Specialist Services’ umbrella) and be accessible through
Sp-ICE (SunQuest ICE web browser functionality for Red
Cell Immunohaematology (RCI) and Histocompatibility and
Immunogenetics (H&I)).
Further information on this project: http://hospital.blood.
co.uk/diagnostic-services/red-cell-immunohaematology/
haemoglobinopathy-genotyping-initiative/
Genotyping Donors:
This is an ongoing project looking at the technology,
feasibility and cost of genotyping donors nationally, with
an aim to cover (where necessary) the genotype variants
seen in haemoglobin disorders.
Discussion
The rationales for genotyping donors and patients
and having this information on a national database are
multiple:
• An evidence base to inform transfusion practice and
needs of this patient group.
• Timely access to patient – and donor-related information
with results available before critical clinical scenarios.
• Reduced workload for laboratory staff and no need
for repeated testing as all results available in a central
location.
• Improve the quality of NHSBT’s expert medical and
scientific support in blood provision.
• Improved compliance with current guidelines.
• Support of blood projection analysis for a hard to
resource patient group.
Expansion of antibody data on Haematos would be a
further improvement though the issues of NHSBT reporting
transfusion results not processed in a NHSBT laboratory
would have to be finessed.
Dr Sara Trompeter
Consultant Haematologist and Paediatric
Haematologist
University College Hospital London NHS
Foundation Trust and NHSBT Colindale
Email: sara.trompeter@uclh.nhs.uk
References:
Adams, R.J., McKie, V.C., Brambilla, D., Carl, E.,
Gallagher, D., Nichols, F.T., Roach,S., Abboud, M.,
Berman, B., Driscoll, C., Files, B., Hsu, L., Hurlet, A.,
Miller, S., Olivieri, N., Pegelow, C., Scher, C., Vichinsky, E.,
Wang, W., Woods, G., Kutlar, A., Wright, E., Hagner, S.,
Tighe, F. & Waclawiw, M.A. (1998) Stroke prevention trial
in sickle cell anemia. Controlled clinical trials, 19, 110-129.
BCSH (1996) Guidelines for pre-transfusion compatibility
procedures in blood transfusion laboratories. BCSH Blood
Transfusion Task Force. Transfus Med, 6, 273-283.
Chou, S., Jackson, T., Vege, S., Smith Whitley, K.,
Friedman, D. & Westhoff, C. (2013) High prevalence
of red blood cell alloimmunization in sickle cell disease
despite transfusion from Rh-matched minority donors.
Blood, 122, 1062-1071.
Chou, S.T., Liem, R.I. & Thompson, A.A. (2012)
Challenges of alloimmunization in patients with
haemoglobinopathies. Br J Haematol, 159, 394-404.
Committee, U.N.S. (2013) Sickle Cell and Thalassaemia:
Data Report 2012/13. 60.
Elhence, P., Solanki, A. & Verma, A. (2014) Red blood
cell antibodies in thalassemia patients in northern India:
risk factors and literature review. Indian Journal of
Hematology and Blood Transfusion, 30, 301-308.
< 24 Blood and Transplant Matters – June 2015

Lee, M.T., Piomelli, S., Granger, S., Miller, S.T.,
Harkness, S., Brambilla, D.J. & Adams, R.J. (2006) Stroke
Prevention Trial in Sickle Cell Anemia (STOP): extended
follow-up and final results. Blood, 108, 847-852.
Matteocci, A. & Pierelli, L. (2014) Red blood cell
alloimmunization in sickle cell disease and in
thalassaemia: current status, future perspectives and
potential role of molecular typing. Vox Sanguinis,
106, 197-208.
Reed, W.F. & Vichinsky, E.P. (1999) Transfusion practice
for patients with sickle cell disease. Current opinion in
hematology, 6, 432-436.
Singer, S.T., Wu, V., Mignacca, R., Kuypers, F.A.,
Morel, P. & Vichinsky, E.P. (2000) Alloimmunization and
erythrocyte autoimmunization in transfusion-dependent
thalassemia patients of predominantly asian descent.
Blood, 96, 3369-3373.
The Order of St John Award for Organ Donation
Organ donation is one of the greatest gifts one person
can give to another. The contributions donors make to
society are immeasurable. Annual increases in donation
over the past six years are helping so many people, that
transplant waiting lists have fallen in number for the first
time. These achievements should not be hidden, which
is why recognition for such selfless contributions is so
important. Donor recognition honours and remembers the
gift of donation, and provides the opportunity to promote
organ donation to the community.
Recommendation 12 of the 2008 Organ Donation
Taskforce report, acknowledged this by calling for,
“Appropriate ways should be identified of personally
and publicly recognising individual organ donors, where
desired. These approaches may include national memorials,
local initiatives and personal follow-up to donor families.”
Yet, until very recently, there were no national recognition
programmes for deceased organ donation in the UK. Any
recognition was usually ad hoc, hospital-based, or through
the good work of the Donor Family Network. After
commencing discussion in 2012, initiated by Mr Terence
Foster an Organ Donation Committee Chair, the Order of
St John entered into a formal partnership with NHS Blood
and Transplant (NHSBT) in 2013, that has led to a new
national award to recognise deceased organ donors.
The Order of St John traces its origins back 900 years
to the Knights Hospitaller from whom they derive their
maxims – ‘Pro Fide, Pro Utilitate Hominum’, ‘For the Faith
and in the Service of Humanity’. Today the Order of St
John has over 400,000 members worldwide and in the
UK, through their subsidiary charity St John Ambulance, is
the country’s leading provider of first aid services and, has
over 40,000 volunteers.
Many have been honoured in the past by the Order of
St John and its membership is multi-faith.
“St John’s focus on primary health care, especially
amongst the poorest of the poor, and its capacity to
tap the most generous and caring human impulses,
gives it a special place in our hearts” Nelson Mandela,
Knight Grand Cross of the Order of St John.
As an order of Chivalry of the British Crown the Grand
Prior of the Order is always a senior member of the British
Royal Family. Currently the Grand Prior is HRH The Duke of
Gloucester, cousin to Her Majesty The Queen. The Order
of St John is able to institute new awards of recognition
and did so with the creation of The Order of St John Award
for Organ Donation. This award has been recognized
internationally throughout the organisation.
The award offers donors and their families’ public
acknowledgment at a level carrying high respect and
recognition. The concept of the award was closely
modeled on The Elizabeth Cross, posthumously awarded
by the Crown to the men and women who have died in
military service for their country and, which is presented
discreetly to the closest family relatives at local ceremonies.
The posthumous Order of St John Award for Organ
Donation, displaying the words ‘add life, give hope’, was
presented to 33 representative donor families from around
the UK by the TRH The Duke and Duchess of Gloucester on
September 18th 2013, at the symbolic first ceremony held
at St James’s Palace, London. Following the award launch,
all families who indicated they are willing to receive further
contact by NHSBT are offered the opportunity to accept
the award on behalf of their family member who donated.
In 2013, over six hundred families accepted the award by
post or more commonly, at local ceremonies throughout
the UK, often presided by a Lord-Lieutenant, Her Majesty
the Queen’s local representative. In 2014, the number of
families accepting was over 800.
Blood and Transplant Matters – June 2015 25 >

‘It was an amazing day. I felt it was so dignified and
yet with a very touching personal feel to it. The fact
that everyone was there to honour our loved ones
and to feel the compassion from all of you from the
NHS and St. John’s was truly wonderful and a day
I will remember forever. Also to be in a room with
other families who have had the same experience
somehow was comforting.’ Anonymous family
feedback, 2014.
Preserving human life is the fundamental purpose of
The Order of St John and this shared ethos with NHSBT
underpins this unique award. We believe it is the only
award of its kind in the world, though other countries
are watching with interest. Initially the award was only
available for deceased organ donors, who donated after
April 2012. Following requests by families, whose loved
one donated prior to this date, the award is now open for
all deceased organ donors who have ever donated in the
UK, a heritage of giving, that extends back to the 1970s.
The NHSBT strategy to deliver a revolution in public
behaviour, as part of the Taking Organ Transplantation to
2020, will seek to further develop the award ceremonies as
high profile annual celebrations of the generosity of donors
and their families. The opportunity we now have to offer
national recognition delivered locally, acknowledges the
altruistic gift made to help others in the midst of personal
loss. Even the most experienced Doctors and Specialist
Nurses are humbled many times over, by the generosity
of donor families. Publically recognising the huge impact
behind the small word ‘yes’ is the least we can do.
The Order of St John Award
It might have taken us nearly forty years to get here
but finally, through The Order of St John Award for Organ
Donation, we are paying tribute to the proud contribution
of organ donors and their families, in adding life and giving
hope to others.
Dale Gardiner
Deputy National Clinical Lead for Organ
Donation
NHSBT
Email: dalegardiner@doctors.net.uk
The Reverend Canon Dr Paul Denby MBE JP DL
Chancellor of the Priory of England and the
Islands
The Order of St John
< 26 Blood and Transplant Matters – June 2015

CPD Questions
1. Patient Blood Management in Clinical
Haematology – Conference Resume:
a) ‘Better Blood Transfusion’ initiatives over the last
16 years have almost eliminated inappropriate
use of unsafe practices.
b) Four per cent of the eligible donor population
actually donate blood.
c) NHSBT take over two million donations every
year.
d) In England, Patient Blood Management
Recommendations were launched in July 2013.
2. During 2013:
a) Less than 50 per cent of all transfusion incidents
were caused by human error.
b) There were no ABO incompatible Red Cell
Transfusions
c) There were 22 deaths where transfusion was
cause or contributory
d) There were less than 100 reports associated with
major morbidity
3. Non-Medical Authorisation of Blood
Components:
a) Blood and blood components prescription
requires an individual to be a registered medical
practitioner.
b) Any nurse can now authorise or prescribe blood
for transfusion.
c) Has particular application in all hospital areas.
d) Can lead to reduced waiting times for day
patients.
4. Patient Blood Management in Clinical
Haematology – Conference Resume:
a) Acute Transfusion Reactions are common, seen
in over one in 1,000 components transfused.
b) Post-transfusion increment data is vital to help
inform future HLA-selected platelets.
c) There is a low prevalence of bleeding in patients
with haematological malignancy.
d) National comparative Audit: use of platelets in
Haematology (2010) results have not affected
the platelet demand.
5. Intra-operative Cell Salvage (ICS):
a) Surgery in obstetrics and gynaecology is the
most frequent user of ICS.
b) Over 90 per cent operated ICS outside normal
working hours.
c) All anaesthetic trainees received theory or
practical.
d) Over 90 per cent had a policy for ICS in their
organisation.
6. Recommendation following 2014 Survey of ICS:
a) No requirement for provision of ICS to be
reviewed by hospital transfusion committee.
b) No requirement for every hospital providing ICS
to have an up to date policy for it’s’ use.
c) Recording of autologous transfusion should have
some stringent standing as seen in allogeneic
transfusions.
d) ICS incidents are out with the SHOT Scheme.
7. Blood Stocks Management Scheme: (BSMS)
a) Can immediately solve all stock management
problems.
b) Can confirm that your hospital practices are well
controlled.
c) Cannot compare similar hospitals.
d) Does not have categories that can be added or
subtracted to change comparisons.
8. Harvey’s Gang:
a) Patient Blood Management (PBM) involves only
clinical staff.
b) Laboratory visits by patients are to be
discouraged.
c) Patient Blood Management can successfully
involve the patient.
d) Has resulted in a lowering of laboratory morale.
Blood and Transplant Matters – June 2015 27 >

9. Involving, Informing and consenting patients
receiving Red Cell Transfusion:
a) Most patients felt they were involved
in transfusion decision.
b) Under one tenth of respondents explicitly felt
they had not been involved.
c) Few Trusts have a policy which requires staff
to inform patients about the risks, benefits
and alternatives to transfusion.
d) Over half of patients recalled been given
information regarding transfusion.
10. Patients recalled:
a) Risks were explained in over 50 per cent.
b) Alternatives were offered in over 50 per cent.
c) Consent was offered in less than 50 per cent.
d) Benefits were discussed in over 50 per cent.
11. National Comparative Audit of Anti-D
Immunoglobinopathy Prophylaxis Routine
Antenatal Anti-D prophylaxis (RAADP):
a) Less than 50 per cent use a single 1500iu anti-D
Ig injection at 28-30 weeks gestation.
b) Less than 80 per cent of eligible RhD negative
women received at least one anti-D Ig injection.
c) Full compliance was better with the twodose
regime.
d) Full compliance was better with the single
dose regime.
13. Potentially Sensitising Event (PSE) requiring
Anti-D Ig:
a) Antepartum Haemorrhage represented over
50 per cent of cases.
b) Still birth represented over 50 per cent of cases.
c) 96 per cent received correct dose for gestation.
d) Anti-D Ig was given to over 99 per cent of
the documented PSE’s.
14. Therapeutic Apheresis (TA) Services in North
West England and North Wales:
a) Over 44 per cent reported difficulties in gaining
access to TA in an emergency.
b) Most over 50 per cent refer to NHSBT.
c) Most over 50 per cent was performed in home.
d) Most over 50 per cent refer out but not
to NHSBT.
15. Haemoglobinopathies of Genotyping:
Typical donor exposive of a patient with Sickle Cell
Disease on an automated exchange programme
equals the following number of units per annum.
a) 35.
b) 45.
c) 64.
d) 87.
12. Post-Delivery Prophylaxis:
a) Over 99 per cent of RhD Negative women
delivering RhD positive babies had post-delivery
prophylaxis.
b) Nearly 92 per cent of RhD Negative women
delivering RhD positive babies had the right dose
at the right time.
c) Volume of fetal cells in FMH was 2 mls or less
in 97 per cent.
d) Over 1 per cent of women needed additional
anti-D Ig to prevent sensitisation.
The CPD Section is a self-assessment exercise which allows readers to evaluate their understanding of each article. The
answers are to be found within the articles themselves. Most CPD schemes allow this type of exercise to be eligible for
credits as self-directed learning.
< 28 Blood and Transplant Matters – June 2015

Clinical Case Studies
We have had the following comment:
“Sorry this is a bit late, but I’ve only just had a chance to
read the Clinical Case Study in the January 2015 Issue of
Blood and Transplant Matters.
I have a couple of Comments
Firstly, the patient’s Hb is given as 8.2g/dL; should this not
be 82g/L?
Secondly, with regard to determining the patient’s correct
ABO type, there is an old-fashioned test that seems to have
gone out of favour, but may help in such a case. This test is
the inhibition of anti-A, anti-B and anti-H by the patient’s
saliva. Admittedly, the patient has to be a secretor, but
there is an 80% chance that he would be, and the ABH
substance in the saliva would be purely his own, rather
than be contaminated with ABH substance from any
transfused blood components. I note the final paragraph
states that, “It should be noted that in some individuals the
genotype does not reflect phenotype. In addition, PCR for
ABO is subject to an error rate and clinical decisions should
interpret the results within the clinical context and the
serological results.” I agree totally with these comments,
and wonder if an inhibition test (at least in 20% of the
population) might not be just as safe”.
We totally agree with your comments.
Question 1
A six-year old child was admitted with Hb 90g/L, with
antecedent viral infection. Two days later Hb dropped to
62g/L. The bilirubin level, was 40 µmol/l (normal range
2-17 µmol/l) with raised LDH. You are provided with DAT
and ABO grouping results. No free antibody detectable
by IAT/papain-treated erythrocytes at 37°C. The child was
transfused with two red blood cell units. Post transfusion
HB level was 94g/L. Two days later Hb dropped to 43 g/L.
Again, no free antibody detected, by IAT/papain treated
erythrocytes at 37°C on this admission.
1) You are provided with DAT and ABO Grouping
results:-
a) Comment on the DAT and ABO grouping findings.
b) What is the likely blood group?
c) How would you confirm the patient’s ABO group?
2)
a) What is the most likely diagnosis?
b) What further laboratory investigations would you carry
out to confirm the diagnosis? Outline the principle of
this test.
3) The child needs further transfusion.
a) What blood would you select?
b) What further measures would you take?
ABO Blood Group Results (Room Temperature 20°C)
Case
No.
DAT Results
Patient’s red cell
reaction with:
Patient’s plasma
reaction with:
A1 A1
Anti-A Anti-B Anti-A,B Anti-A1
B O
RBCs RBCs RBCs RBCs
0 5 5 0 5 5 2 2
Polyspecific AHG IgG C3d Control
++ - ++ -
Question 2
A 70-year old female patient presented with tiredness.
Examination revealed mild sclera icterus. The bilirubin was
at 52 (normal range 2-17 µmol/l) and LDH level was 2,049
iu/l (normal range 310-620). Full blood count showed Hb
80g/L, MCV 112 fl and whole blood count 8x10 9 /L with
a platelet count of 160x10 9 /L. You were provided with
red blood cells indices and ABO grouping, DAT results.
Antibody screen by standard IAT at 37°C was negative.
A. Automated Full Blood Count and Red Cell Indices
Patient Normal range
RBC count 0.56 x 10 9 /µl 4.0-5.2 x 10 9 /µl
Hemoglobin 80 g/L 115-155 g/L
Hematocrit 6.4% 35%-45%
Mean Cell Volume 112 fL 77.0-95.0 fL
B. ABO Blood Group Results (Room Temperature 20°C)
Case
No.
Patient’s red cell
reaction with:
Patient’s plasma
reaction with:
A1 A1
Anti-A Anti-B Anti-A,B Anti-A1
B O
RBCs RBCs RBCs RBCs
5 0 5 5 2 2 5 2
C. DAT with Warm Washed Cells:
Polyspecific AHG IgG C3d Control
+++ - +++ -
1.
a) Comment on Full Blood Count Results?
b) You were asked to repeat Full Blood Count,
how would you proceed?
2.
a) What is the likely blood group?
b) How would you confirm the patient’s ABO group?
3. Antibody screen and identification revealed no
free antibody detectable by IAT and papaintreated
erythrocytes at 37°C. Based on the DAT
results and all the above finding, what is the
most likely diagnosis? Give reasons.
4. What further serological investigations would
you carry out to determine the possible
diagnosis?
5. What are the clinical conditions which may be
associated with the above disorder?
Blood and Transplant Matters – June 2015 29 >

Answers to Clinical Case Studies
Question 1
1. a) DAT by complement only. Reverse grouping
reacting with all cell tested at RT (cold antibody).
b) Blood group B with cold antibody.
c) Sample warm washed at 37ºC with saline and
repeat ABO typing.
2. a) PCH.
b) Donath - Landsteiner Test.
c) Detection of biphasic antibody.
d) Antibody binds at lower temperature and causes
complement activation at 37ºC.
e) IgG antibody with anti-P specificity.
3. a) Select blood group B/Rh matched compatible
units.
b) Keep ambient temperature more than 24ºC,
to consider using blood warmer.
c) Only very rarely need pp blood.
Question 2
1. a) Spurious indices due to red cell agglutination.
b) Repeat peripheral blood film prepared at 37ºC.
2. a) Blood group A with cold antibody.
b) Sample warm washed at 37ºC with saline and
repeat ABO typing.
3. c) CHAD with red cell agglutination at RT providing
spurious full blood count results. DAT by
complement only.
4. a) Confirmed IgM cold autoantibody by conducting
direct saline agglutination at 4ºC, 20ºC, and 30ºC.
b) CHAD is defined as cold auto antibody reacting at
or above 30ºC. (High thermal amplitude).
c) studies in general shows high titre at cold
temperature and anti-I specificity.
5. a) Acute: Transient (adolescent or young adults).
b) Infection, M pneumonia, infectious mononucleosis.
c) Chronic more than (50 years of age).
d) Idiopathic: Majority.
e) Secondary remainder.
f) Lympho-proliferative disorders.
g) Lymphoma, CLL.
h) Waldenstrom’s Macroglobulinemia.
< 30 Blood and Transplant Matters – June 2015

Diary Dates
Diary Dates
2015
20-21 May
Surveillance and Screening of Blood Borne
Pathogens
22nd International Workshop
Location: Prague, Czech Republic
For More information contact:
www.isbt.org
21-23 May
19th Training Course on Haemopoietic Stem Cell
Transplantation
Location: Malaga, Spain
For more information contact:
www.esh.org/conferences
3 June
Clinical and Laboratory Haemostasis
Location: The Atrium Conference Centre, Sheffield
Hallam University, Howard Street Sheffield
For more information contact:
www.b-s-h.org.uk
5 June
Haematology for Physicians
Location: BMA House London
For more information contact:
www.b-s-h.org.uk
9-11 June
Stem Cells: From Basic Research to Bioprocessing
Location: Cineworld: The 02, Peninsula Square
London
For more information contact:
www.b-s-h.org.uk
11-13 June
13th International Cord Blood Symposium
Location: San Francisco
For more information contact:
www.cordbloodsymposium.org
2014
12 June
Emerging and Re-emerging Infectious Diseases
Location: Edinburgh
For more information contact
www.b-s-h.org.uk
12-15 June
19th EHA Annual Congress
Location: Milan, Italy
For more information contact:
www.b-s-h.org.uk
27 June – 1 July
Scotblood
Location: Stirling Universtiy, Scotland
For more information contact:
www.bbts.org.uk/events
27 June – 1 July
25th Regional Congress of the ISBT in
Conjunction with the 33rd Annual Conference of
the British Blood Transfusion Society
Location: London
For more information contact:
www.isbtweb.org/events-congresses
29 June
UK NEWQAS for Leucocyte Immunophenotyping
Scientific Meeting
Location: Sheffield Hallam University, Sheffield
For more information:
www.ukneqas.org.uk
8-10 September
The 2015 Tissue Engineering Congress
Location: Cineworld: The 02, Peninsula Square,
London
For more information contact:
www.b-s-h.org.uk
Blood and Transplant Matters – June 2015 31 >

28-29 September
The Future for Blood and Plasma Donations
2nd Global Symposium
Location: Fort Worth (Dallas), TX, USA
For more information contact
www.bbts.org.uk/events
30 October
Red Cell Special Interest Group
Location: NHSBT Filton Blood Centre, Bristol
For more information contact
www.bbts.org.uk/events
10-11 November
UK NEQAS (BTLP), BBTS & BSH Joint Meeting
Location: Birmingham Motorcycle Museum
For more information contact
www.bbts.org.uk/events
1-2 December
Improving Access to Plasma and Plasma Products
in the Southern African Region
Location: Stellenbosch (Cape Town), South Africa
For more information contact
www.bbts.org.uk/events
< 32 Blood and Transplant Matters – June 2015

Notes
CPD Blood and
Transplant Matters
1. D
2. C
6. D
7. B
11. B
12. D
Answers Issue 44
3. B
8. C
13. B
4. C
9. D
14. D
5. A
10. A
15. C
Blood and Transplant Matters – June 2015 33 >

Notes
< 34 Blood and Transplant Matters – June 2015

Notes
Blood and Transplant Matters – June 2015 35 >

Blood and Transplant Matters is prepared
and issued by NHS Blood and Transplant,
Oak House, Reeds Crescent, Watford, Herts WD24 4QN
(Telephone 0114 358 4804)
MI423.11 1516066