Expired blood, untraceable donors and poor record-keeping – the Madhya Pradesh health department has found several lapses as part of its investigation into how five children with thalassemia, who received blood transfusions at Satna’s Vallabhbhai Patel District Hospital, tested HIV-positive.
A “chargesheet” by the state’s Directorate of Public Health and Medical Education against the blood bank’s suspended in-charge, Dr Devendra Patel, and two lab technicians reveals how the public health system failed to keep children dependent on monthly transfusions safe. The report states that “proper records of blood donors were not maintained, company details/batch numbers of testing kits were missing, and blood was not properly tested for HIV/other tests before transfusion”.
The case first came to light in December last year, though the children were detected with HIV in March and April 2025.
Dr Patel, who has since been suspended, refused to comment on the allegations.
The probe found that questionnaires, which were supposed to capture each donor’s address, occupation, and haemoglobin level, were incomplete. Blood was allegedly collected “without health checks or haemoglobin assessments,” yet “records falsely showed all donors having haemoglobin> 12g/dl”. The counsellor post was vacant, and in its absence, “no counselling or screening of donors was performed by the blood centre officer or other staff”, it found.
The donation room, which handled 40 to 50 donors daily, was allegedly managed by one person at a time, with “unauthorised/suspicious persons seen frequently”. Register entries were found blank, and blood collected at the Maihar civil hospital, a separate facility, was being “issued from Satna records without following the Drug and Cosmetics Act or national guidelines”, it states.
There were alleged lapses in testing, too. The transfusion transmissible infection (TTI) protocol requires all donated blood to be screened for HIV, hepatitis B, hepatitis C, malaria, and syphilis. The HIV test must be conducted using 4th Generation ELISA or CLIA – advanced diagnostic methods sensitive enough to detect infection in its earliest stages. But the investigation found that between January 2024 and March 2025, “out of 204 units issued to infected children, 35 units were tested only by Rapid Card (17%) instead of CLIA”. Rapid Card tests are cheaper, faster, and less sensitive. The blood centre officer’s explanation was that “CLIA reagents were not consistently available”.
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The investigation extended to Birla Blood Centre, a private facility whose license allegedly lapsed in August 2024. Inspection of its registers allegedly found that “several expired blood units were issued, including one to a thalassemia-affected girl”. One HIV-infected child had allegedly been issued three units from this centre across 2020 and ߨ another is stated to have received one unit in February 2024. On the question of what happened to donors who tested reactive for HIV, the report states, “Donors found HIV reactive were not referred to ICTC centres as per rules; no referral records were found”.
Similar gaps ran through the state’s own HIV care infrastructure. Between January 2024 and March 2025, the blood bank at the district hospital allegedly produced 14 TTI-reactive donors. Only five were allegedly traceable in the antiretroviral therapy centre records. The other nine had no records — their current HIV status unaddressed, their whereabouts unknown.
The five children suffering from thalassemia had tested HIV positive at the Sardar in Satna between March and early April last year.
The Birla Blood Centre declined to comment on the development. An official at the Satna district hospital said, “The probe is being carried out by multiple authorities, which will fix accountability. That report will be sent to the state health department, which will take further action.”
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When contacted, Dr R N Pandey, the in-charge of the Maihar civil hospital, said that the facility would collect blood in various blood donation camps and send it to Satna. “We sent blood samples to Satna after collecting them from blood donation camps. These samples were not tested since that responsibility lay with Satna district hospital. After the investigation, we have stopped supplying blood samples to Satna,” he said
