During a bypass case a Temed D200 (M03265) haemoconcentrator was used. During the case I had filtered off 500ml and then switched the haemoconcentrator off. During this time I had 'flushed' the device every 5-10 minutes to ensure blood was not stagnating until the time I found unable to do so towards the end of the case. After some inspection, I had noticed clumping at the exit point of the haemoconcentrator, then I had noticed that there was visible clot within the line and at the ends within the haemoconcentrator device; the device was not used after this point. ACTs were all above 400 seconds during the time the haemoconcentrator was used.

The patient involved was known to be HIV positive, therefore the device was not kept for inspection due to the infection control risk. This is the second filter of the same batch number that this has occurred with in this hospital recently. The filter supplier was informed after both incidences.