Shared Learning

Cautionary Tales

Transplant recipients' deaths following kidney transplant - publication of investigation reports

In December 2013, two patients died after receiving kidney transplants from the same donor. It was a tragic and rare case. At the time of death, the donor was showing signs of encephalitis of an unknown cause. The donor was characterised and the organs were offered.

After death, the cause of the donor's encephalitis was identified as Halicephalobus gingivalis, an extremely rare infection that has only been reported in humans five times previously in the medical literature.

Sadly, the recipients of the donor's organs both died a few weeks after their transplants.

NHS Blood and Transplant and the other organisations involved thoroughly investigated what happened.

We are publishing our internal NHS Blood and Transplant investigation into the incident together with an external Review we commissioned, to ensure that colleagues working in organ donation and transplantation across the UK can also take learning from this sad case.

NHS Blood and Transplant has carefully considered our own investigation report, the investigation carried out on behalf of the hospital where the transplants were carried out and the external review we commissioned, which was completed by Professor O'Donoghue and Dr Gunning. The action plans we agreed stemming from the recommendations within these reports are published further below.

Final investigation report and accompanying appendices

Final investigation report (INC 423 Transmission of donor infection) dated 31st March 2014 Appendix 1 - Offering sequence of liver and cardiothoracic organs Appendix 3 - Transcript of telephone conversation between 1) Recipient Coordinator, University Hospital of Wales, Cardiff and 2) Duty Officer, NHS Blood and Transplant

Please note that the Duty Officer is highly trained but not clinically qualified

Appendix 4 - Duty office call log
Appendix 5 - Microbiology screening results

Further information about our final investigation report and appendices

NHSBT's purpose is to save and improve lives and we manage the NHS Organ Donor Register which is a national, confidential list of people who are willing to become donors after their death. We go to great lengths to maintain the strictest confidence of organ donors, and their families, at all times. Confidentiality is the cornerstone of organ donation.

NHSBT has therefore chosen not to publish Appendix 2 (EOS Core Donor Data Form) which accompanies the final investigation report. This contains clinical information regarding the donor, as well as details of the donor's social and medical background known at the time of donation. The duty of confidentiality owed to the donor extends beyond death.

Further, any information contained within the documentation listed above which pertains to the identity or location of the donor and the donor's treating hospital has been redacted.

The names of those involved in the care of the donor and recipients have been redacted.

Except for Professor James Neuberger, NHSBT's Associate Medical Director for Organ Donation and Transplantation, the names of those involved in the investigation have also been redacted. NHSBT is of the view that their members of staff and those involved in the investigation have a reasonable expectation to privacy. Their roles have however been stated, except in cases where that would enable the donor or the donor's location to be identified.

Any additional information contained within the documentation listed above regarding the donor’s social and medical background has been redacted. As already stated, the duty of confidentiality owed to the donor extends beyond death and any information gathered which constitutes clinical records has been redacted.

Overview of Reports into the Incident of the Transmission of Donor Infection for NHS Blood and Transplant

Click here to view the O'Donoghue and Gunning report

Report authors:
Dr Kevin Gunning, Past consultant in Anaesthesia and Intensive Care, Addenbrooke’s Hospital 1990-2014 and Director of John Farman Intensive Care Unit 2001-2010

Donal O’Donoghue, Professor of Renal Medicine at Manchester University and Consultant Nephrologist at Salford Royal Hospital since 1992

Background to this report

NHS Blood and Transplant was asked by the Welsh Health Department to commission an overview report into the circumstances surrounding the deaths of two renal transplant patients from donor transmitted encephalitis in December 2013 in a Welsh hospital. The scope of this review is from the point of referral of the potential donor to the point of death of the transplant recipients.

Action plan - 13th November 2014
This action plan includes the actions arising from our own investigation and the investigation carried out on behalf of the hospital.

Action plan - 26th November 2014
This action plan includes actions arising from the O'Donoghue and Gunning Report.

Coroners report
Report to prevent future deaths - December 2014

https://www.judiciary.gov.uk/publications/darren-hughes/
https://www.judiciary.gov.uk/publications/robert-stuart/

NHS Blood and Transplant official response to coroner

Letter sent to coroner - 10 February 2015
Glossary of terms

Glossary of terms

Page published 4 December 2014

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