Manchester Newborn Screening Laboratory Quarterly Blood Spot … · 2019. 11. 27. · Bury 1 1 0%...

1 Aisha Rahman & Beverly Hird 26/11/19 CB-REP-REP-10

Manchester Newborn Screening Laboratory Quarterly Blood Spot

Screening Report: Quarter 2 2019-20

Manchester Newborn Screening Laboratory, which serves babies born in Greater

Manchester, Lancashire and South Cumbria, received 14386 blood spot samples between 1st

July and 30th September 2019. This report describes performance against the NHS Newborn

Blood Spot Screening Programme Standards. Full details of the standards including

definitions and exclusions can be found at https://www.gov.uk/government/publications/

standards-for-nhs-newborn-blood-spot-screening. The appendix of this document contains

the data for standards 3-7 in table form.

The data for the laboratory reportable standards is presented by maternity unit/NHS trust of the sample taker. For accurate figures, please ensure the trust code is written/stamped on the blood spot card (in the PCT field). The proportion of samples with a missing maternity unit/trust code is presented in figure 1 by CCG. Overall the maternity/ trust code was missing from 215 sample cards (1.5%).

Declines In quarter 2 the laboratory received 42 notifications of declined blood spot screening. Figure 2 shows the trends in declined screens over the past year, by place of birth (born in UK or born outside of UK). The laboratory should be notified of all declines, including those for babies screened elsewhere, rather than directly notifying Child Health.


0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

Born inUK

BornOutside

UK

NotStated

Born inUK

BornOutside

UK

NotStated

Born inUK

BornOutside

UK

NotStated

Born inUK

BornOutside

UK

NotStated

Q2 19-20 Q1 19-20 Q4 18-19 Q3 18-19Rat

e o

f d

ecl

ine

d b

loo

d s

po

t sc

ree

nin

g p

er

10

00

bab

ies

Place of Birth

Figure 2 - Blood Spot Screening Declines

Declined, screened outside UK with no evidence of result (0204)

Declined, screened outside UK with evidence of result (0203)

Declined, screened in UK (as reported by parents) with no evidence of result (0202)

Declined, no history of being screened (0201)


Key to colour coding

Met achievable threshold

Met acceptable threshold

Within 10% of acceptable threshold

More than 10% below acceptable threshold

Standard 3 – The proportion of blood spot cards received by the laboratory with the

baby’s NHS number on a barcoded label

Acceptable: ≥ 90.0% of blood spot cards are received by the laboratory with the baby’s NHS number on a barcoded label. Achievable: ≥ 95.0% of blood spot cards are received by the laboratory with the baby’s NHS

number on a barcoded label.

Figure 3 displays performance against standard 3.

Overall, 86.2% of samples received July to September 2019 had a barcoded NHS number

label, which is slightly higher than quarter 1 (85.9%). Of 11 maternity units, 5 met the

standard, including two reaching the achievable threshold (East Lancashire and Lancashire

Teaching).

Standard 4 - The proportion of first blood spot samples taken on day 5

Acceptable: ≥ 90.0% of first blood spot samples are taken on day 5. Achievable: ≥ 95.0% of first blood spot samples are taken on day 5. Figure 4 displays performance against standard 4. Overall, 91.9% of samples received July to September 2019 were collected on day 5. Of 11 maternity units, 9 met standard 4, which is similar to quarter 1 (91.1%; 10 units met the standard). As for last quarter, only Manchester FT met the achievable threshold.


Standard 5 - The proportion of blood spot samples received less than or equal to 3

working days of sample collection

Acceptable: ≥ 95.0% of all samples received less than or equal to 3 working days of sample collection.

Achievable: ≥ 99.0% of all samples received less than or equal to 3 working days of sample collection.

Performance against the transport standard (figure 5) was good. Overall 98.1% samples

were received within 3 working days. 10 Trusts met the standard, including 6 reaching the

achievable threshold. Performance was very similar to the last quarter (98.3% samples

received within 3 working days). Performance continues to worsen for Southport and

Ormskirk (less than 70% of samples received within 3 working days).

Standard 6 - The proportion of first blood spot samples that require repeating due to an

avoidable failure in the sampling process

Acceptable: Avoidable repeat rate is ≤ 2.0%

Achievable: Avoidable repeat rate is ≤ 1% The avoidable repeat rate for quarter 2 was 2.3%, which is lower than last quarter (2.6%).

The performance for each trust is displayed in figure 6. Five Trusts met the standard.

Blackpool and Tameside met the achievable standard. Figure 7 compares the avoidable

repeat rate for samples collected from in-patients with sample collected from babies at

home/ in the community. The rate was 1.7% for babies at home (lower than quarter 1 –

2.2%) and 7.2% for samples collected from in-patients (6.3% in quarter 1).

2).


0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

9.0%

10.0%

11.0%

12.0%

Avo

ida

ble

re

pea

t ra

teFigure 6: Standard 6 - The proportion of first blood spot samples that require

repeating due to an avoidable failure in the sampling process

Insufficient No NHS number Expired card Contaminated IRT <5 days Missing sample date Other


Excluded from chart: Royal Blackburn Hospital (avoidable repeat rate 50%; 1 out of 2 samples), Royal Manchester Children’s Hospital

(avoidable repeat rate 22.2%; 2/9 samples), Ormskirk and District General (avoidable repeat rate 21.7%; 5/23 samples) and Royal Lancaster

Infirmary (no avoidable repeats).

0%

2%

4%

6%

8%

10%

12%

Avo

idab

le r

ep

eat

rate

Figure 7: Standard 6 - Avoidable repeats for in-patients vs community

Insufficient quantity No NHS number Expired card Contaminated (discrepant IRT) <5 days Missing sample date Other


Trust STD 3 STD 4 STD 5 STD 6

Blackpool Teaching Hospitals NHS FT 94.0% 93.0% 99.6% 0.9%

Bolton NHS FT 78.9% 92.3% 99.2% 2.7%

East Lancashire Hospitals NHS Trust 95.5% 92.9% 99.3% 1.8%

Lancashire Teaching Hospitals NHS FT 97.3% 94.7% 98.6% 1.9%

Manchester University NHS FT 93.5% 95.1% 99.2% 2.8%

Pennine Acute Hospitals NHS Trust 81.8% 89.3% 97.0% 2.1%

Southport & Ormskirk Hospital NHS Trust 79.5% 89.5% 69.8% 12.0%

Stockport NHS FT 92.0% 91.9% 99.5% 2.9%

Tameside And Glossop Integrated Care NHS FT 81.8% 94.6% 99.6% 0.8%

University Hospitals of Morecambe Bay NHS FT 89.7% 93.1% 98.9% 2.5%

Wrightington, Wigan and Leigh NHS FT 60.0% 91.0% 98.9% 2.0%

Q2 19-20 Table 1 - Summary of performance


Standard 7a - The proportion of second blood spots for raised IRT taken on day 21 to day

24

Acceptable: ≥ 95% of second blood spot samples taken on day 21 to day 24 Achievable: ≥ 70% of second blood spot samples taken on day 21

The acceptable threshold was not met for Standard 7a. During quarter 2 there were 8

repeats for raised IRT (CF inconclusive). Of these, 38% (3) were collected on day 21 and 88%

(7) on day 21-24. CF inconclusive repeats are performed by Screening Link Health Visitors.

The data is presented in figure 7 and by local Child Health Records Department, in table 2.

Day 2137%

Day 2237%

Day 2413%

Day 2713%

Figure 7: Standard 7a - The proportion of second blood spots for raised IRT taken on day 21 to day 24

21 22 24 27

c/o Birmingham Screening Lab 1 1 0% 100%

Bolton 1 1 100% 100%

Bury 1 1 0% 100%

Central Lancashire/Chorley 1 1 0% 100%

Oldham 1 1 2 0% 50%

Rochdale 1 1 100% 100%

c/o Sheffield Screening Lab 1 1 100% 100%

Grand Total 3 3 1 1 8 38% 88%

Q2 Table 2 - Standard 7a

% collected

day 21-24Child Health Records Department Grand Total

%

collected

day 21

Age at Collection of CF Inconclusive Repeat

(days)


Standard 7b - The proportion of second blood spot samples for borderline TSH taken

between 7 and 10 calendar days after the initial borderline sample

Acceptable: ≥ 95.0% of second blood spot samples taken as defined Achievable: ≥ 99.0% of second blood spot samples taken as defined Standard 7b was not met. Figure 8 displays the proportion collected 7-10 days after the initial sample and table 3 displays the information by Trust.

6 7 8 9 10 11 12 18 28

Blackpool Teaching Hospitals NHS FT 2 2 100%

Bolton NHS FT 1 1 1 3 67%

East Lancashire Hospitals NHS Trust 1 1 100%

Lancashire Teaching Hospitals NHS FT 1 1 2 100%

Manchester University NHS FT - SMH & RMCH 1 1 2 100%

Manchester University NHS FT - Wythenshawe 1 1 1 3 33%

Not Stated 1 1 100%

Pennine Acute Hospitals NHS Trust 1 1 1 1 1 1 1 7 57%

Stockport NHS FT 1 1 2 100%

Tameside And Glossop Integrated Care NHS FT 1 1 2 0%

Wrightington, Wigan and Leigh NHS FT 1 1 100%

Grand Total 1 1 5 6 6 4 1 1 1 26 69%

Trust

% collected

7-10 days

after

original

sample

Grand

Total

Number of days between original sample and collection of

repeat sample

Q2 Table 3: Standard 7b


Standard 7c - The proportion of CHT pre-term repeats collected on day 28 or at discharge

Acceptable: ≥ 95.0% of second blood spot samples taken as defined

Achievable: ≥ 99.0% of second blood spot samples taken as defined

Standard 7c was not met. During quarter 2, 107 CHT pre-term repeats (second samples only,

avoidable repeats excluded) were received. Performance by trust is displayed in figure 9.

77% were collected on day 28 or at discharge. 5% were collected too early and required a

further repeat. 19% were collected after day 28.

Of note, 4 out of 20 babies with samples collected after day 28 had transfusions on days 25-

28, which would account for the delayed sampling.

Standard 9 - Timely processing of CHT and IMD (excluding HCU) screen positive samples

Acceptable: 100% of babies with a positive screening result (excluding HCU) have a clinical

referral initiated within 3 working days of sample receipt

14 samples screened positive for CHT during quarter 2. 100% of babies were referred within

3 working days.

There were 6 IMD positives (excluding HCU) and all were referred within 3 working days.

Standard 11 - Timely entry into clinical care

Data for standard 11 is displayed in table 4.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Figure 9: Standard 7c - The proportion of CHT pre-term repeats collected on day 28 or at discharge


Condition Criteria Thresholds

Number of

babies seen by

specialist

services by

condition

specific

standard

Number of

babies

referred

Percentage

seen by

specialist

services by

condition

specific

standard

Comments

IMDs (excluding HCU)

Attend first clinical

appointment by 14 days of

age

Acceptable: 100% 6 6 100%

CHT (suspected on first

sample)



age


CHT (suspected on repeat

following borderline TSH)



age


3 babies not seen by std: Baby 1) First sample had

no sample date, repeat on day 10, borderline

repeat on day 17. Appointment day 23. Baby 2)

Repeat sample collected day 16 (borderline on

day 6). Appointment day 22. Baby 3) Repeat

sample collected day 33. Appointment day 39.

Incident.

CF (2 CFTR mutations

detected)



age

Acceptable: ≥ 95.0%

Achievable: 100%5 5 100%

Excluding one case detected prior to screening

due to abdominal obstruction.

HCU



age

Acceptable: ≥ 95.0%

Achievable: 100%0 0 N/A

CF (1 or no CFTR mutation

detected)



age


appointment by 35

days of age

0 0 N/A

SCD



age


appointment by 90

days of age

1 1 100%

Table 4: Standard 11


Incidents

Figure 10 displays blood spot screening incidents identified by the lab or notified to the lab. A summary table of incidents is included in the

appendix.

Blood spot collection error:delay/ failure to collect

screening sample

Blood spot labelling error:handwritten NHS numberbelonging to another baby(other demographic details

correct)

Blood spot transport issue:sample(s) delayed in transit butretesting of baby not required

Lab reporting error: resultreported as not suspected

instead of carrier

4 - major incident severity 0 0 0 0

3 - moderate incident severity 0 1 0 1

2 - minor incident severity 0 0 0 0

1 - low incident severity 2 0 2 0

0

1

2

Nu

mb

er

of

inci

de

nts

Figure 10: Blood spot screening incidents identified by Manchester lab or notified to lab - quarter 2 2019/20


Appendix

TrustNumber of a ll

samples (including

repea ts)

Number of blood

spot cards

including baby's

NHS number

Number of blood

spot cards

including ISB labe l

barcoded baby's

NHS number

Percentage of a ll

blood spot cards

including babies'

NHS number

Percentage of a ll

blood spot cards

including ISB bar-

coded babies'

NHS number

Blackpool Teaching Hospitals NHS FT 815 815 766 100.00% 93.99%

Bolton NHS FT 1653 1651 1304 99.88% 78.89%

East Lancashire Hospitals NHS Trust 1730 1726 1653 99.77% 95.55%

Health Visitor 110 107 6 97.27% 5.45%

Lancashire Teaching Hospitals NHS FT 1065 1065 1036 100.00% 97.28%

Manchester University NHS FT 2646 2641 2474 99.81% 93.50%

Not Stated 215 215 177 100.00% 82.33%

Pennine Acute Hospitals NHS Trust 2732 2719 2236 99.52% 81.84%

Southport & Ormskirk Hospital NHS Trust 273 273 217 100.00% 79.49%

Stockport NHS FT 817 817 752 100.00% 92.04%

Tameside And Glossop Integrated Care NHS FT 787 787 644 100.00% 81.83%

University Hospitals of Morecambe Bay NHS FT 716 716 642 100.00% 89.66%

Wrightington, Wigan and Leigh NHS FT 827 826 496 99.88% 59.98%

Grand Total 14386 14358 12403 99.81% 86.22%

Quarter 2 2019-20: Standard 3


Trust

Number of

first samples

taken on or

before day 4

5 6 7 8 9+4 or

earlier5 6 7 8 9 or later

Blackpool Teaching Hospitals NHS FT 0 740 42 7 2 5 0.00% 92.96% 5.28% 0.88% 0.25% 0.63%

Bolton NHS FT 1 1376 86 10 4 14 0.07% 92.29% 5.77% 0.67% 0.27% 0.94%

East Lancashire Hospitals NHS Trust 5 1480 77 21 3 7 0.31% 92.91% 4.83% 1.32% 0.19% 0.44%

Health Visitor 0 0 0 0 0 88 0.00% 0.00% 0.00% 0.00% 0.00% 100.00%

Lancashire Teaching Hospitals NHS FT 3 959 44 0 2 5 0.30% 94.67% 4.34% 0.00% 0.20% 0.49%

Manchester University NHS FT 5 2286 88 8 11 7 0.21% 95.05% 3.66% 0.33% 0.46% 0.29%

Not Stated 0 174 12 4 0 1 0.00% 91.10% 6.28% 2.09% 0.00% 0.52%

Pennine Acute Hospitals NHS Trust 4 2331 205 31 7 32 0.15% 89.31% 7.85% 1.19% 0.27% 1.23%

Southport & Ormskirk Hospital NHS Trust 0 212 18 3 1 3 0.00% 89.45% 7.59% 1.27% 0.42% 1.27%

Stockport NHS FT 0 723 56 4 1 3 0.00% 91.87% 7.12% 0.51% 0.13% 0.38%

Tameside And Glossop Integrated Care NHS FT 0 734 31 4 2 5 0.00% 94.59% 3.99% 0.52% 0.26% 0.64%

University Hospitals of Morecambe Bay NHS FT 0 634 35 5 0 7 0.00% 93.10% 5.14% 0.73% 0.00% 1.03%

Wrightington, Wigan and Leigh NHS FT 0 730 62 7 2 1 0.00% 91.02% 7.73% 0.87% 0.25% 0.12%

Grand Total 18 12379 756 104 35 178 0.13% 91.90% 5.61% 0.77% 0.26% 1.32%

Excludes samples with missing dates



3

Maternity Unit

Number of samples

received in 3 or

fewer working days

of sample being

taken

Total number of

samples received

Percentage of

samples received by

laboratories in 3 or

fewer working days

of sample being

taken

Blackpool Teaching Hospitals NHS FT 809 812 99.6%

Bolton NHS FT 1552 1564 99.2%

East Lancashire Hospitals NHS Trust 1640 1651 99.3%

Health Visitor 92 97 94.8%

Lancashire Teaching Hospitals NHS FT 1041 1056 98.6%

Manchester University NHS FT 2514 2533 99.2%

Not Stated 197 206 95.6%

Pennine Acute Hospitals NHS Trust 2629 2710 97.0%

Southport & Ormskirk Hospital NHS Trust 187 268 69.8%

Stockport NHS FT 812 816 99.5%

Tameside And Glossop Integrated Care NHS FT 782 785 99.6%

University Hospitals of Morecambe Bay NHS FT 699 707 98.9%

Wrightington, Wigan and Leigh NHS FT 816 825 98.9%

Grand Total 13770 14030 98.1%



Status code and description of avoidable

repeat

Blackpool

Teaching

Hospitals

NHS FT

Bolton NHS

FT

East

Lancashire

Hospitals

NHS Trust

Health

Visitor

Lancashire

Teaching

Hospitals

NHS FT

Manchester

University

NHS FT

Not

Stated

Pennine

Acute

Hospitals

NHS Trust

Southport &

Ormskirk

Hospital NHS

Trust

Stockport

NHS FT

Tameside And

Glossop

Integrated Care

NHS FT

University

Hospitals of

Morecambe

Bay NHS FT

Wrightington,

Wigan and

Leigh NHS FT

Grand Total

0301: too young for reliable screening (≤ 4

days)0 1 5 0 2 5 0 3 0 0 0 0 0 16

0302: too soon after transfusion (<72

hours)0 6 5 0 1 7 1 2 0 0 0 0 0 22

0303: insufficent sample 1 18 7 2 4 21 1 8 4 5 2 1 9 83

0304: unsuitable sample (blood quality):

incorrect blood application2 17 8 1 4 28 0 13 19 11 2 4 4 113


compressed/damaged 0 0 0 0 1 3 0 4 0 1 0 1 0 10

0306: Unsuitable sample: day 0 and day 5

on same card0 0 0 0 0 0 0 0 0 0 0 0 0 0

0307: unsuitable sample for CF: possible

faecal contamination1 3 3 0 0 3 0 5 0 3 1 3 0 22

0308: unsuitable sample: NHS number

missing/not accurately recorded0 1 2 3 0 3 0 12 0 0 0 0 1 22

0309: unsuitable sample: date of sample

missing/not accurately recorded3 1 3 0 5 4 0 10 5 1 1 7 2 42

0310: unsuitable sample: date of birth not

accurately matched0 0 0 0 0 0 0 0 0 0 0 0 0 0

0311: unsuitable sample: expired card

used0 0 1 0 3 0 0 0 0 2 0 0 0 6

0312: unsuitable sample: >14 days in

transit, too old for analysis0 0 0 0 0 0 0 0 1 0 0 1 0 2

0313: unsuitable sample: damaged in

transit0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of Avoidable Repeat Requests 7 41 29 6 19 67 1 55 29 23 6 17 16 316

Number of first samples received/

babies tested799 1492 1597 101 1018 2409 196 2620 242 788 778 688 804 13532

Avoidable Repeat Requests Rate 0.9% 2.7% 1.8% 5.9% 1.9% 2.8% 0.5% 2.1% 12.0% 2.9% 0.8% 2.5% 2.0% 2.3%

Transfusion Reapeats are not included in the Avoidable Repeat calculation

Quarter 2 2019-20: Standard 6 by Trust


Status code and description of

avoidable repeat

Blackpool

Victoria

Hospital

Burnley

General

Hospital

Furness

General

Hospital

North

Manchester

General

Hospital

Not in

hospital

Ormskirk

& District

General

Royal

Albert

Edward

Infirmary

Royal

Blackburn

Hospital

Royal

Bolton

Hospital

Royal

Lancaster

Infirmary

Royal

Manchester

Childrens

Hospital

Royal

Oldham

Hospital

Royal

Preston

Hospital

St Mary's

Hospital,

Manchester

Stepping Hill

Hospital

Tameside

General

Hospital

Wythenshawe

Hospital

Grand

Total

0301: too young for reliable screening (≤ 4

days)0 3 0 0 7 0 0 0 1 0 1 1 0 3 0 0 0 16

0302: too soon after transfusion (<72

hours)0 5 0 0 1 0 0 0 6 0 1 2 1 5 0 0 1 22

0303: insufficent sample 0 4 0 3 64 0 2 0 3 0 1 1 1 2 0 0 2 83


incorrect blood application1 5 2 3 54 5 1 1 10 0 0 4 1 15 3 1 7 113


compressed/damaged 0 0 0 1 5 0 0 0 0 0 0 0 1 3 0 0 0 10

0306: Unsuitable sample: day 0 and day 5

on same card0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0307: unsuitable sample for CF: possible

faecal contamination0 0 0 0 19 0 0 0 1 0 0 1 0 1 0 0 0 22

0308: unsuitable sample: NHS number

missing/not accurately recorded0 1 0 0 16 0 1 0 0 0 0 3 0 1 0 0 0 22

0309: unsuitable sample: date of sample

missing/not accurately recorded1 2 0 1 34 0 0 0 1 0 0 1 1 0 0 1 0 42

0310: unsuitable sample: date of birth not

accurately matched0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0311: unsuitable sample: expired card

used0 0 0 0 6 0 0 0 0 0 0 0 0 0 0 0 0 6

0312: unsuitable sample: >14 days in

transit, too old for analysis0 0 0 0 2 0 0 0 0 0 0 0 0 0 0 0 0 2

0313: unsuitable sample: damaged in

transit0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of Avoidable Repeat Requests 2 15 2 8 207 5 4 1 16 0 2 11 4 25 3 2 9 316

Number of first samples received/

babies tested64 148 18 95 12020 23 53 2 173 47 9 188 118 311 73 54 136 13532

Avoidable Repeat Requests Rate 3.1% 10.1% 11.1% 8.4% 1.7% 21.7% 7.5% 50.0% 9.2% 0.0% 22.2% 5.9% 3.4% 8.0% 4.1% 3.7% 6.6% 2.3%

Transfusion Reapeats are not included in the Avoidable Repeat calculation

Quarter 2 2019-20: Standard 6 by Current Hospital


Early On time Late Total

Blackpool Teaching Hospitals NHS FT 3 1 4 75% 75%

Bolton NHS FT 1 8 1 10 80% 90%

East Lancashire Hospitals NHS Trust 1 7 7 15 47% 53%

Lancashire Teaching Hospitals NHS FT 8 8 100% 100%

Manchester University NHS FT 28 4 32 88% 88%

Pennine Acute Hospitals NHS Trust 2 14 5 21 67% 76%

Southport & Ormskirk Hospital NHS Trust 1 1 0% 100%

Stockport NHS FT 2 2 100% 100%

Tameside And Glossop Integrated Care NHS FT 2 1 3 67% 67%

University Hospitals of Morecambe Bay NHS FT 6 6 100% 100%

Wrightington, Wigan and Leigh NHS FT 4 1 5 80% 80%

Grand Total 5 82 20 107 77% 81%

Quarter 2 2019-20: Standard 7c

Trust

Number of Pre-term CHT second samples collected: % Prem repeats

collected on day

28 or at discharge

% Prem repeats

collected on day

28 or earlier


Incident

Number

Incident

Date

Incident

Severity

Incident

HarmSummary of incident Further details

Lab/ Ward/ Maternity

Unit

2077750 12/07/193 -

moderate2 - slight

Blood spot labelling error:

handwritten NHS number belonging

to another baby (other demographic

details correct)

Royal Oldham NNU

2078268 05/07/19 1 - low1 - no

harm

Blood spot transport issue:

sample(s) delayed in transit but

retesting of baby not required

Day 12 sample received (?

first sample discarded in

error)

Ward C2, Wythenshawe

2078270 05/07/19 1 - low1 - no

harm

Blood spot transport issue:

sample(s) delayed in transit but

retesting of baby not required

Day 12 sample received (?

First sample discarded in

error)


2078871 12/12/183 -

moderate

1 - no

harm

Lab reporting error: result reported

as not suspected instead of carrier

Newborn Screening CF

result reported incorrectly

as not suspected instead

of carrier due to IT

problem.

NBS Lab

2078656 18/07/19 1 - low1 - no

harm

Blood spot collection error: delay/

failure to collect screening sample

Day 5 samples found in

patient files (twins, wrong

way round), day 12

samples had already been

sent.


2084214 17/08/19 1 - low1 - no

harm

Blood spot collection error: delay/

failure to collect screening sampleDay 5 home viist missed. SMH Community Midwives

Manchester Newborn Screening Laboratory Quarterly Blood Spot … · 2019. 11. 27. · Bury 1 1 0%...

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