In these 23 years, the investigators have lost track of the victim; the convicted blood bank officer has retired; and her lab assistant, who too was charged, is no more.
Twenty-three years after a typhoid patient admitted to JJ Hospital was transfused with HIV infected blood, a metropolitan magistrate last month sentenced the blood bank's officer to two years of rigorous imprisonment and imposed a fine of Rs 15,000 on her.
In these 23 years, the state's home department has lost track of the victim; the convicted blood bank officer has long retired and is well into her 70s; and her lab assistant, who was also charged, has passed away.
Food and Drug Administration (FDA) officials, who pursued the case doggedly through the long trial, say that this is a first conviction in a case of negligence by a blood bank.
The convicted blood bank officer Dr Jyotsna Desai, who was attached to the Tata Blood Bank and Transfusion Centre at JJ Hospital, was charged under several sections of the Drugs and Cosmetic Act and Section 269 (Negligent act likely to spread infection of disease dangerous to life) of the Indian Penal Code.
The victim, a 13-year-old girl from Jalgaon, who was suffering from typhoid, anaemia and chronic inflammation, was admitted to JJ Hospital in August 1991. She was transfused with a unit of blood (serial no 5198) obtained from the Tata Blood Bank and Transfusion Centre which was then run by the Sir Dorabji Tata Trust.
While going through the records, Dr Desai realised that blood unit no 5198, which was marked HIV+ve by the AIDS Surveillance Centre, was missing. An internal investigation revealed that the unit was wrongly labled HIV -ve by lab assistant Arjun Sawant and placed on a rack where blood units marked safe to be issued to patients were placed.
The court ruled that though the error was made by the lab assistant, Dr Desai in her capacity as his supervisor should have detected the mistake and not allowed the infected blood unit to be issued to the Jalgaon girl.
The FDA came to know about the case though a small report in a regional newspaper in September 1991. Taking cognizance of the report, the FDA began its investigation and called for the patient's blood sample from Jalgaon.
Test reports stated that the sample tested positive for HIV in Elisa test. Test result for Western Blot Test, however, was indeterminate.
FDA's joint commissioner Sanjay Kale, who was then a drug inspector, said that the victim's relatives did not remain in contact with the investigators. "We followed up the case thoroughly as it involved serious negligence," said Kale, adding that the licence of the blood bank was soon cancelled after which the state government decided to open its own blood bank in JJ Hospital.
"It's a cautionary tale for blood banks. They must exercise extreme care in testing, labeling, and issuing blood units."
FDA joint commissioner B R Masal, who was a complainant in the case, said the case helped tighten controls over testing and labeling of blood units in blood banks. "When this unfortunate incident happened, we were just learning about the deadly HIV infection," he said.
Desai's lawyer Prakash Kilpady said his client will challenge the order in a higher court. "Desai was made a scapegoat when she was not the main in-charge. She had superiors too. Also, the labeling was done by Sawant who died a few years ago," said Kilpady.
He also pointed out that there were no tests carried out to determine the age of the HIV infection in the patient, suggesting that the victim may have picked up the infection even before she was admitted to JJ Hospital.
Twenty-three years after a typhoid patient admitted to JJ Hospital was transfused with HIV infected blood, a metropolitan magistrate last month sentenced the blood bank's officer to two years of rigorous imprisonment and imposed a fine of Rs 15,000 on her.
In these 23 years, the state's home department has lost track of the victim; the convicted blood bank officer has long retired and is well into her 70s; and her lab assistant, who was also charged, has passed away.
Food and Drug Administration (FDA) officials, who pursued the case doggedly through the long trial, say that this is a first conviction in a case of negligence by a blood bank.
The convicted blood bank officer Dr Jyotsna Desai, who was attached to the Tata Blood Bank and Transfusion Centre at JJ Hospital, was charged under several sections of the Drugs and Cosmetic Act and Section 269 (Negligent act likely to spread infection of disease dangerous to life) of the Indian Penal Code.
The victim, a 13-year-old girl from Jalgaon, who was suffering from typhoid, anaemia and chronic inflammation, was admitted to JJ Hospital in August 1991. She was transfused with a unit of blood (serial no 5198) obtained from the Tata Blood Bank and Transfusion Centre which was then run by the Sir Dorabji Tata Trust.
While going through the records, Dr Desai realised that blood unit no 5198, which was marked HIV+ve by the AIDS Surveillance Centre, was missing. An internal investigation revealed that the unit was wrongly labled HIV -ve by lab assistant Arjun Sawant and placed on a rack where blood units marked safe to be issued to patients were placed.
The court ruled that though the error was made by the lab assistant, Dr Desai in her capacity as his supervisor should have detected the mistake and not allowed the infected blood unit to be issued to the Jalgaon girl.
The FDA came to know about the case though a small report in a regional newspaper in September 1991. Taking cognizance of the report, the FDA began its investigation and called for the patient's blood sample from Jalgaon.
Test reports stated that the sample tested positive for HIV in Elisa test. Test result for Western Blot Test, however, was indeterminate.
FDA's joint commissioner Sanjay Kale, who was then a drug inspector, said that the victim's relatives did not remain in contact with the investigators. "We followed up the case thoroughly as it involved serious negligence," said Kale, adding that the licence of the blood bank was soon cancelled after which the state government decided to open its own blood bank in JJ Hospital.
"It's a cautionary tale for blood banks. They must exercise extreme care in testing, labeling, and issuing blood units."
FDA joint commissioner B R Masal, who was a complainant in the case, said the case helped tighten controls over testing and labeling of blood units in blood banks. "When this unfortunate incident happened, we were just learning about the deadly HIV infection," he said.
Desai's lawyer Prakash Kilpady said his client will challenge the order in a higher court. "Desai was made a scapegoat when she was not the main in-charge. She had superiors too. Also, the labeling was done by Sawant who died a few years ago," said Kilpady.
He also pointed out that there were no tests carried out to determine the age of the HIV infection in the patient, suggesting that the victim may have picked up the infection even before she was admitted to JJ Hospital.