Board Assails Health Officials : County: Supervisors harshly criticize King/Drew personnel over HIV-tainted transfusion.

Los Angeles County supervisors expressed outrage Tuesday that officials at the county’s Martin Luther King Jr./Drew Medical Center overlooked problems at the hospital’s blood bank that contributed to a woman receiving a transfusion of deadly HIV-tainted blood last year.

The supervisors’ criticism of health officials came in the wake of a Times article describing problems at the blood bank that investigators said led to the transfusion on June 30, 1994, and as they considered a $450,000 settlement proposal in the case. Aleta J. Clemons, the blood’s recipient and a mother of three, is showing symptoms of AIDS.

Also Tuesday, the former head of the U.S. Food and Drug Administration’s Blood Products Division said the case is so rare that it is sure to draw the attention of blood safety analysts nationwide.

“This is startling . . . that in 1994 a hospital is not up to snuff like that,” Dr. Thomas Zuck said. “We haven’t heard of a case like this in at least five years.”

Zuck, who now runs a regional blood center at the University of Cincinnati, said it was only the fourth case to his knowledge out of the millions of transfusions in the United States each year in which a hospital patient was given blood already determined to be HIV-positive.

At their weekly board meeting, county supervisors met in executive session and decided to postpone the malpractice settlement, with sources saying members want to find a way to give Clemons more financial help, perhaps lifetime medical benefits. They also said the case has raised a host of serious concerns.

For more than an hour, the supervisors harangued officials they had summoned from the beleaguered hospital and trauma center near Watts and top administrators from the Department of Health Services that oversees it.

Board Chairman Mike Antonovich accused health administrators of giving Clemons, 44, “a death sentence” through their incompetence and lack of oversight.

“You have an obligation to the public that the blood that is being received has been tested to be free of any type of AIDS or communicable disease,” Antonovich said. “With this breakdown, there was a violation of that trust. And now a woman with three young children--if she becomes incapacitated, how are you going to raise those three children?

“The amount of the settlement is very low for the death sentence that she has received,” Antonovich added.

Contrite health officials agreed that more could have been done to prevent the transfusion and to improve conditions at the blood bank.

After the transfusion, county and federal investigators criticized the blood bank for a host of problems, including poor training and communication among staff and a lack of safeguards that could have prevented release of tainted blood.

“We totally agree with you that this should never have happened,” said Mary Jung, acting director of the Department of Health Services. She said staff members at the blood bank were overworked, and that the transfusion was primarily the result of human error.

Nevertheless, Jung said, “We needed to provide additional training and oversight, and that we have [now] done.”

She added: “We have taken some severe disciplinary actions against the whole [blood bank] team,” including demotions, suspensions and dismissals.

Unsatisfied, supervisors demanded a better explanation of what happened in the Clemons case and more assurances that a similar occurrence could not happen at the county’s blood banks. The supervisors also asked that there be more discipline for those involved.

Several low-level nurses were ousted, but their supervisors were punished less severely, even though they were blamed in internal investigations for many of the problems that led up to the transfusion.

Dr. William Temple, head of transfusion services, said in an interview that he received a 30-day suspension, was transferred out of the blood bank and had his pay cut $70 a month.

“These people received demotions? Big deal,” said Supervisor Gloria Molina, a frequent critic of officials within King/Drew and the health department. “I want them to be fired. The punishment was not sufficient.”

Citing the county’s internal investigation into the matter, Molina said: “It is unbelievable the number of people who dropped the ball on this, from top to bottom. Basically, the bottom line here is total incompetence within the [health] department and the hospital.”

Molina also accused health officials of trying to hide the problems at the blood bank.

“When did you brief our staffs on this?” Molina asked rhetorically. “Try never. They have never even alerted us about this.”

But the hospital’s medical director, Edward Savage, said the board was notified of the incident in a detailed memo shortly after it happened.

Walter Gray, assistant county health director in charge of hospitals, said a host of improvements have been put in place systemwide as a result of the incident and the blood bank at King/Drew no longer tests blood.

Gray said safeguards have been instituted at the county’s other blood bank at Harbor/UCLA Medical Center--measures that federal and county officials said were missing at King/Drew.