An urgent review has been ordered into the Queensland Heart Valve Bank after a serious breach, with the Health Department revealing four patients – including three babies – were given tissue from a donor who had brain cancer.
Chief health officer Dr Jeannette Young said the breach happened more than a year ago, but was not discovered until earlier this month during an unrelated audit.
The babies were less than a year old and the other patient was a young adult.
Dr Young said it was highly unlikely the tissue was cancerous and that there is little risk to patients, whose families were notified during the week.
The last family to be notified was informed on Friday morning.
“Of course they’ll be anxious, distressed, horrified, and I extend my deep and sincere apologies to them – it should never have happened,” Dr Young said.
She said it was too early to say whether people should lose their jobs over the breach.
“It looks like this was a one-off incident, one error. At this stage we haven’t found any evidence of other issues,” she said.
Dr Young said the three babies received the transplants at the Lady Cilento Children’s Hospital in Brisbane, but the hospital was not responsible for the breach.
‘Extraordinarily low’ risk
Queensland Health director-general Michael Walsh said the initial audit had revealed tissues from a donor with a particular type of brain cancer was incorrectly released for use in heart valve and tissue grafts on the four patients early last year.
“While I’m assured the risk to these patients is extraordinarily low, this is unacceptable and should not have happened,” Mr Walsh said.
Dr Young also said the risk of the patients developing cancer as a result of the grafts was “extraordinarily low”.
“After an exhaustive search of medical literature, we were not able to find an instance where anyone has developed cancer when a tissue graft has been taken from a patient with this type of brain cancer anywhere in the world,” she said.
Dr Young said it was unclear how the breach occurred but said it should never have happened.
She said teams of clinicians check the eligibility of all donations for use, and people who had cancer could still make certain donations.
“In this circumstance, this donor tissue should not have been cleared for use in heart valve and cardiac tissue grafts,” she said.
Dr Young said an initial review of grafts over the past five years suggested no other patients had received potentially contaminated tissue.
Heart Valve Bank closed
The Heart Valve Bank is operated by Metropolitan South Hospital and Health Service (HHS) on behalf of the entire state.
It has been closed since January and the HHS is now formally investigating a range of staffing issues after a number of internal complaints.
Three staff have been stood down pending the outcome of the separate investigations.
Last month, the LNP used Question Time to quiz the Health Minister about the closure of and investigation into the Heart Valve Bank’s operations.
Labor’s Steven Miles told Parliament the six-month closure was not impacting patients or their care.
“It is vitally important that Queenslanders know that when they have a sick kid they can have confidence in their public hospital. They should ignore the claims of those opposite,” he said.
Opposition health spokeswoman Ros Bates said “clearly that was not correct and he now has serious questions to answer”.
Mr Miles was absent from today’s press conference with Queensland Health.
“Labor’s Steven Miles should be answering the tough questions today and not hiding behind Dr Jeannette Young,” Ms Bates said.
In a statement Mr Miles asked the director-general to commission an investigation.
“He has ordered a full, independent, external review of the Heart Valve Bank to determine how and why this happened, and what measures need to be put in place to prevent it ever happening again,” he said.
“I want this review to find out why this happened, and make sure it never happens again.”
Mr Walsh said the review would also determine what — be it any system, procedural or clinical issues — contributed to the error.
The review is expected to be finalised by the end of the year.
Prior to its closure, the bank distributed cardiovascular tissue across Queensland and interstate for use in surgery, most commonly in children and infants with congenital heart disease.
Tissues required for Queensland patients will now be sourced from interstate heart valve banks until compliance can be assured.
Opposition health spokeswoman Ros Bates said she was “extremely concerned” by the “utterly unacceptable incident”.
“There has clearly been a major failure within the system that has resulted in potentially cancerous tissue given to four Queensland children,” she said.
She said she hoped the children make a full recovery from the ordeal.
“This is another blight on our public health system and a failure from this Labor minister,” she said.