Contamination from condensation on foam boxes containing blood bags might have caused a Tuen Mun Hospital patient's fatal transfusion reaction on January 7, an investigation panel has found.

The 52-year-old man was admitted for a red-cell blood transfusion on January 3. After two hours of transfusion he went into shock with severe shortness of breath and a drop in blood pressure. He was transferred to the intensive care unit and later died.

Laboratory tests found the Pseudomonas fluorescens bacterium in his blood and the blood bag.

Panel chairman Professor Yuen Kwok-yung today said problems might have arisen when lorries transported foam boxes containing blood bags from the Red Cross Blood Transfusion Centre to Tuen Mun Hospital.

"When we opened these foam boxes we found condensation on the surface of the coolants which are used to ensure blood bags are kept at a temperature below 20 degrees Celsius," he said.

Microbiological tests found the condensation might have been contaminated with the bacterium which then spread into the bag through tiny surface cracks, contaminating the blood.

Noting the incident was rare, Prof Yuen said no frontline medical staff should be held responsible for the unfortunate case.

The panel recommended:

* avoiding condensation, and disinfection of foam box containers;

* clarifying blood-transfusion guidelines;

* implementing auditing programmes to ensure medical staff are following the guidelines; and,

* considering selective and empirical use of one dose of antibiotics for unexplained post-transfusion shock and fever.

Secretary for Food & Health Dr York Chow has asked the Hospital Authority to examine the report and quickly implement the recommendations to enhance patient care and service standards, and maintain a high standard in blood donation and transfusion services.

Dr Chow said the panel has reassured all professionals involved have followed international standards and guidelines in their service.