“For the Chief Executive, NHSBT (1) The core donor data form could have contained more…”

The coroner’s concerns

– For the Chief Executive, NHSBT (1) The core donor data form could have contained more information as to the second lumbar test performed on the donor and could have given the results of the first lumbar puncture test. (2) There was information available on the medical microbiology report which was not passed on to the accepting transplant centre. Had this information been available to the accepting consultant then it may have caused more questions to be asked and aided in the acceptance process. The Coroner is concerned that NHSBT should employ systems to ensure the capture and transmission of all relevant information to the accepting transplant centre, and that SNODs should be in a position if required to certify that all relevant and available information has been transmitted. For the Chief Executive, UHW Cardiff (1) The Kidneys were accepted by the transplant centre following a telephone conversation between the consultant and the transplant coordinator. The Coroner heard that all consultants have access to the EOS system but that the consultant did not use it on this occasion. The Coroner is concerned that a viewing of the EOS system should be standard practice by all accepting consultants/centres before a decision is made, as the information on EOS is much fuller than anything that can be conveyed over the telephone. (2) The kidneys were accepted by the consultant acting alone. The Coroner heard evidence that in many centres the acceptance process is conducted on a “team” basis, with the consultant accepting advice from microbiologists and even other on call consultant surgeons. The Coroner is concerned that a team approach offers the most informed method of decision making, not only over the decision to accept organs but also over the nature and duration of prophylactic anti-viral therapy. The Coroner is concerned to hear about any action that is being taken over this in the transplant centre. (3) The Coroner heard that a standard consent form is used for all operations, and heard evidence that this has proved unsatisfactory for transplant operations where issues have to be covered that are not catered for by the standard form 2 (4) These deaths represent (including the donor) the 5th, 6th and 7th recorded cases in the world of deaths caused by the Halicephalobus nematode. They are the first ever recorded deaths caused by human to human transmission. The Coroner is concerned that a written account of these deaths should be made available to the wider transplant community and that an article should be written for an appropriate journal (subject to consents from the families of the deceased). Such an article could be written in collaboration between the pathologist, the transplant centre and the microbiologists concerned in this inquest.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2014-0549

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8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0