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A Report On The Case Of Intravenous Injection For Patients Who Can Not Eat

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On 7th March 1972, the Daily Telegraph [1] published the news that 500 bottles of 5% dextrose drip-feed solution were urgently traced by the Department of Health since they may have been contaminated. Five patients, four men, and a woman died at the Devonport hospital in Plymouth between 29th February and 2nd March. The common factor among these patients was each had been given infusions of the 5% dextrose fluid manufactured by Evans Medical Ltd., of Speke, Liverpool. The dextrose solution is used by intravenous injection for patients who cannot eat including post-operative patients. The suspect batch coded D1192/C, originally consisting approximately 660 bottles, was manufactured in May 1971 by Evans Medical. A joint statement was issued…show more content…
With steam continuously entering the autoclave from the top, the air inside the autoclave would be displaced. When the displacement finishes, all the contents in the autoclave would reach and be held at the required temperature, giving the satisfactory sterilisation cycle. There are six autoclaves in the Transfusion Unit at Evans Medical, each consists of a pressure gauge and a dial thermometer at the top and a recording thermometer with an inserted recorder sensor in the condensate drain. There was evidence given by the autoclave operator and supervisor that occasionally the temperature recorders of autoclaves numbers 4, 5, and 6 either show a temperature below 240 or fail to indicate any rise above the baseline from about December 1970. When this happened, technicians were called to inspect the autoclaves. Normally, the recorder would work again and the sterilising cycle will be continued. On most of the occasions, the technician advised the supervisor that the temperature recorder was broken but the supervisor ignored his advice and continued using the autoclaves. In fact, the manager of the Transfusion Unit had requested for replacement of all six recorders but the request was not followed up. In consequence, in the event of the recorder not functioning, the staff continued the production if the dial thermometer and the pressure gauge were working properly and indicating correct temperature and pressure.

On 6th April 1971, a batch of 5% dextrose
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