A 27 year old woman was admitted for treatment of a 5mm celulus obstructing the distal third of her right ureter. The kidney was damaged previously because of a congenital kink at the upper end of the same ureter. The kidney was functioning poorly and in danger of further damage. The urologist performed a pydoplasty to remove the kink from the ureter and a nephrotomy to provide drainage from the kidney. Before the operation, he ordered a pint of blood to be made available for transfusion. The blood was not used and was sent back to the blood bank.

When subsequent attempts to remove the stone by cystoscopy failed, the doctor scheduled a second operation. Because he expected this operation to be brief, he ordered no blood.

Shortly before the second operation began, a circulating nurse in the operating room, an employee of the hospital, found a note on the desk saying “The patients blood is in the refrigerator.” Wrongly assuming that the blood was for the person in the operating room, she gave the blood to the nurse anesthetist in the case, an employee of the hospital anaesthetist.

The operation turned out to be longer than anticipated. In the course of the operation, the nurse anaesthetist said to the surgeon, “Doctor I have a pint of blood for this patient, shall I give it to her now?”

Assuming that this was the pint of blood he had ordered for the first operation, the doctor replied, “Yes give it to her.”

Ten hours later the lady was dead.

The patient’s husband sued the surgeon, the hospital, as employer of the circulating nurse, and the anaesthetist who was not even present but was the employer of the nurse anaesthetist.

All three were found liable and had to pay.