MAUDE Adverse Event Report: Leica Biosystems Melbourne Pty. Ltd HistoCore PELORIS 3 Automated Tissue Processor; Processor, Tissue, Automated

Model Number	HistoCore PELORIS 3 Automated Tissue Processor
Medical Device Problem Code	Improper or Incorrect Procedure or Method (2017)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	08/24/2026
Type of Reportable Event	Malfunction
Event or Problem Description
On 24 august 2026, the customer contacted leica biosystems and reported that ¿tissue through cleaning cycle.Tissues were left in the processor and went through the cleaning cycle, are there any recommendations for ways to mitigate the damage? the blocks are quite crispy.¿ on 29 august 2026, the leica senior applications specialist documented ¿¿all 8 cases have been signed out, diagnosed.Customer also stated that if needed, they could go back to gross tissue for re-grossing for processing.¿.
Additional Manufacturer Narrative
The root cause for the sub-optimal tissue processing reported by the customer was due to a user error.Specifically, the information indicates that a user failed to follow the manufacturer instructions detailed in section 3.2 of the leica histocore peloris 3 user manual, which contains the following specific warning: ¿do not use cleaning protocols for reprocessing as the dry step will damage the tissue.¿ accordingly, exposure of the patient tissue samples to the retort cleaning protocol would have adversely impacted the patient tissue samples.Although the information available indicates that all patient cases involved in this event were diagnosable, the circumstances involved in this complaint have previously resulted in serious injury.No adverse impact on either the quality of processing of patient tissue samples or to any patient(s) has been reported to the manufacturer in association with the circumstances involved in this complaint.Manufacturer evaluation of the information available showed that the instrument functioned as designed during execution of the affected tissue processing run.

• Brand Name: HistoCore PELORIS 3 Automated Tissue Processor
• Common Device Name: Processor, Tissue, Automated
• Manufacturer (Section D): Leica Biosystems Melbourne Pty. Ltd; 495 blackburn road; mount waverley; victoria 00000 0314; AS 0000003149
• Manufacturer (Section G): Leica Biosystems Melbourne Pty. Ltd; 495 blackburn road; mount waverley; victoria 00000 0314; AS 0000003149
• Manufacturer Contact: daya currie ; 495 blackburn road; mount waverley; victoria 00000-0314 ; AS 0000003149 ; +011(613)92117271
• MDR Report Key: 50849963
• Report Number: 8020030-2026-00020
• Device Sequence Number: 15936657
• Product Code: IEO
• UDI-Device Identifier: 09349458004811
• UDI-Public: (01)09349458004811(11)190418
• Combination Product (Y/N): N
• Initial Reporter State: CA
• Initial Reporter Country: US
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Company Representative
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial
• Report Date (Section B): 09/22/2026

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Operator of Device: Health Professional
• Device Model Number: HistoCore PELORIS 3 Automated Tissue Processor
• Device Catalogue Number: 45.0005
• Was Device Available for Evaluation?: Yes
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 08/24/2026
• Initial Report FDA Received Date: 09/22/2026
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 04/18/2019
• Is the Device Labeled for Single Use? (Y/N): No
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Reuse
• Patient Sequence Number: 1
• Patient Sex: Unknown