Killed by a needless blood transfusion "When I said I didn't want a transfusion it was not because I thought I would get vCJD, but because so much of the time they are unnecessary," she says. The doctor looks at the type of surgery they are about to do and decides how many bags of blood they need. They don't think: do we actually need to give this patient blood? It's a claim with which many specialists agree - not least Bruce Keogh, NHS Medical Director, who recently told an audience of transfusion experts that one in five blood transfusions is "unnecessary." Almost three million transfusions using donated blood are given to patients in England and Wales annually. Some of these will save the lives of patients at risk of bleeding to death after an accident or injury, and some will be given to those with severe blood loss following an operation or childbirth. Blood transfusions are also vital for patients with genetic blood disorders such as sickle cell disease, and cancer patients with severe anaemia resulting from chemotherapy. But according to Mike Murphy, professor of blood transfusion medicine at Oxford University, less than 10 per cent of donated blood goes towards such transfusions: "Most blood transfusions are non-urgent, used routinely to 'top up" patients about to undergo planned surgery." Patient blood samples are usually taken before and after routine surgery, and whether a transfusion is given will often depend on levels of haemoglobin, the substance in red blood cells that carries oxygen around the body. Low haemoglobin levels may mean the patient is not getting enough oxygen. Prof Murphy says that despite detailed guidelines on when patients should be given blood, there is evidence that a "significant percentage of transfusions are given outside these recommendations." According to Dr Paula Bolton-Maggs, medical director of the independent group Serious Hazards of Transfusion (Shot), many "inappropriate" transfusions are due to errors made in measuring haemoglobin levels - for example, a sample from an arm that is rigged up to a saline drip. As a result the blood is diluted with saline and the haemoglobin levels appear lower than they actually are. "It's a well-known problem," she says. Errors can also occur where staff write down the wrong numbers on patients" notes, or where machinery designed to read haemoglobin levels during surgery is wrongly calibrated. Low iron levels, which is one cause of low haemoglobin, are a common reason for blood transfusions, Dr Bolton-Maggs points out, but could easily be treated with iron tablets instead. Many patients with mild anaemia caused by low iron end up getting transfused unnecessarily. All patients preparing for elective surgery should have their blood tested beforehand, so that any iron deficiency can be identified and treated. But the problem of needless transfusions is caused not just by error but also by medical attitudes, says Ian Roberts, professor of epidemiology and public health at the London School of Hygiene and Tropical Medicine. "Blood transfusions are engrained in medical culture," he says. A doctor will assess patients for levels of oxygen in the blood, find it's low and think: 'Oh, I'll raise it. It's a bit like cooking - you make a casserole, you taste it and think it's not very salty and you add some salt. Like many interventions that have been used for a long time, the necessity for blood transfusion has never been properly tested. These days both blood and potential donors are screened rigorously for a range of infections, including hepatitis B and C and HIV. Transmission of vCJD is still a concern, despite donated blood being "filtered" to remove the white blood cells likely to harbour the rogue proteins that cause vCJD. That said, there are only four known cases of people dying from vCJD acquired through blood transfusions given in the 1990s, the last fatality being in 2007. Other risks of blood transfusion include anaphylaxis, a life-threatening allergic reaction to the donor blood; lung injury and inflammation; and acute haemolytic transfusion reaction (AHTR), where the immune system reacts against the donated blood, triggering a range of symptoms including fever, vomiting, shock and kidney failure. Last year, according to Shot, blood transfusions were associated with eight deaths, 3,038 reported adverse incidents and 117 cases of major harm. The figures include 180 allergic reactions, including 33 that were potentially life-threatening. The risks are increased by sloppy practice - for example, blood being used past its expiry date, or stored in a faulty refrigerator, or "near-misses" - where staff note abnormalities in blood packs in the nick of time. Then there is the problem of patient mix-ups: this month NHS Blood and Transplant, the UK authority responsible for ensuring the safety of blood transfusions, revealed that this year there were nearly 250 dangerous incidents where blood from the wrong group was given to patients. It has launched a campaign urging patients to double check their identity with medical staff before they receive blood. So what can be done? Prof Murphy says there are several ways to reduce the number of blood transfusions. Giving anaemic patients iron tablets before surgery is one; routinely giving surgical patients tranexamic acid, which reduces blood loss, is another. A procedure called intraoperative cell salvage, in which blood lost from a patient during surgery is collected for use if needed, is also available for some types of surgery. The National Institute for Health and Clinical Excellence (Nice) has meanwhile been commissioned to develop national transfusion guidelines. "Blood is a precious gift from generous donors," Bruce Keogh says. It's important that doctors only prescribe transfusions when they're really needed. This also ensures, he adds, that donated blood is available for those who really need it. Prof Roberts points out that having a blood transfusion is not unlike receiving a donor organ, with similar associated risks. "Blood is actually an organ, a liquid organ," he says. Having a transfusion is an invasive procedure, not so different from receiving a donor organ. As with other health care interventions, we need trials of its effectiveness and safety. Judy Kenny, meanwhile, wants to see patient consent for non-emergency blood transfusions, with an explanation of the risks involved, to be made a legal requirement. "On the anniversary of Deryck's death, a change like this would be welcome," she says. blood.co.uk/about-blood/information-for-patients