Infected organs were transplanted into three patients – one of whom died – after a surgeon failed to warn that he had accidentally cut the donor’s stomach when removing them.
The organs were removed from a patient by the lead surgeon at Oxford University Hospital NHS Foundation Trust and sent to NHS Blood and Transplant, which manages blood, organ, stem cell and tissue donation and transplantation across the UK.
Concerns over the donated organs were then raised by the Cardiff and Vale University Health Board, when a patient of The University Hospital of Wales, who’d undergone a kidney transplant, became seriously unwell.
The patient had to have the organ removed as an emergency and the matter was reported to the Human Tissue Authority. The Welsh Government were also informed.
A full investigation found that two more patients had been affected having received organs from the same donor, one of whom, a 36-year-old, died of an aneurysm caused directly as a result of an infection relating to a donated liver.
A 44-year-old patient who had undergone a kidney and pancreas transplant also suffered abdominal pains and was placed on antibiotics, but suffered no long-term health issues.
It was only during the investigation that the surgeon from Oxford, who initially removed the organs in August 2015, admitted that a ‘small nick’ had been caused to the donor’s stomach during the procedure, leading to ‘some stomach content spill’.
However, the delay in sharing this information meant NHS Blood and Transplant, and the ‘receiving centres’ were not aware of any issue until transplants had been completed and patients developed health problems.
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Kidney transplant patient suffered internal bleeding and feels ‘life was put at risk’
Hudgell Solicitors have successfully represented a patient, who is in their 20s, from South Wales, in relation to the transplant surgery. They suffered internal bleeding and needed their kidney transplant removed.
The patient had an initial kidney transplant as a child, having suffered from moderate chronic renal failure, but in 2014 was diagnosed with acute rejection of the transplant.
It was for that reason that they underwent a second transplant in September 2015 at the University Hospital of Wales in Cardiff.
Three weeks later, having suffered constant pain, the patient was found to have extensive internal bleeding from the transplant site, with the situation so serious that the kidney was removed as an emergency and the patient was put into an induced coma.
After 16 blood transfusions, the patient was started on dialysis immediately and remained in the hospital for three months. They had to remain on dialysis for another year before finally having another transplant, which was this time successful.
The patient, who asked not to be named said they felt their ‘life was put at risk’ by a surgeon ‘covering up’ what had happened.
I think that is completely unacceptable, and it makes you wonder how many other potentially life-threatening mistakes are being made and not owned up to or covered up,
From what I have learned through the investigations and legal process, I feel my life was put at risk. In a way I probably feel lucky to have come through this and be alive.
The reality is that it has had a huge impact on my life. My children were very young at the time and they saw very little of me when I was ill. I now get tired and out of breath quickly also, and have a lot of pains in my legs. I work as an adult support worker, but it is phone based as I can’t do anything excessive.
Although the patient had been on a waiting list for a transplant in 2015 to replace the one donated by their mother when aged seven, they were not in a rush as they were not on dialysis and were feeling ‘fit and healthy’ at the time. The patient added:
I knew my original transplanted kidney would need replacing but there wasn’t a rush. I was fit and well, playing sport and regularly cycling 20 miles.
When I was offered the transplant it seemed great news because it meant it had come available before I started to feel ill and before I needed dialysis. It seemed perfect timing.
However, from the day it went in everything went wrong. It needed to be taken out and put back in because of initial problems and swelling, then when I did return home I was in constant pain.
I went to the clinic because of the pain and when I stood up in the waiting room I was covered in blood. That was the last I remember as I collapsed and I ended up in a coma.
To find out later, when you have been so ill, that a surgeon knew he had made a mistake, and hadn’t owned up to it, was incredible. I find it disgusting and totally unacceptable.
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Substantial damages agreed following legal cases against Oxford Hospital Trust
Oxford University Hospital NHS Foundation Trust has now agreed on a damages settlement of over £215,000 for the patient, following legal action led on their behalf by medical negligence specialist Dimple Raja, of Hudgell Solicitors.
The Trust admitted it had been in breach of duty by the failure of the surgeon to record the cut into the donor’s stomach. In defence of the legal action, lawyers acting on behalf of the Trust claimed that despite the stomach spill, even if known at the time of transplant, the risk would have been considered low.
It added that ‘the forming of an opinion of donor risk is not an exact science and there is a significant variance of accepted practice nationally.’
Solicitor Mrs Raja says it was ‘a completely unacceptable breach of duty of care’ which was ‘extremely damaging for patient trust in surgeons’. She said:
No matter what the outcome had been in this case, the failure to ensure that everybody involved was aware of the serious accident which occurred when removing the organs from the donor was reckless on the part of the surgeon.
It denied all involved, from the patients to the surgeons transplanting the organs, the knowledge of the full facts. It cannot be excused at any level. It was a completely unacceptable breach of duty of care.
My client and the two other patients were put at life-endangering risk as a result. This was entirely avoidable and this sort of behaviour is extremely damaging for patient trust in surgeons.
Mrs Raja said her client had been left with ‘life-limiting’ problems as a result of nerve damage linked to the removal of the infected kidney, suffering from continued pains in their legs and feet, high blood pressure and breathing difficulties. She said:
My client has regrettably been left with permanent serious health issues,
Patient information and choice has been at the heart of this case. It is now established law that doctors must consult with patients concerning all material risks and to disregard the patient’s right to know of those risks when consenting to a procedure as serious as a kidney transplant is particularly concerning.
In this case, the cut to, and spillage from the donor’s stomach, raised the risk of organ contamination and the associated risk that the transplanted organ would fail.
Any patient receiving a transplanted organ would no doubt have considered this an issue of real significance.
Had the transplant surgeon been made aware of this they also would have been duty bound to have discussed the associated risks with our client and to consider with them whether they were willing to take that risk.
At the time our client was very young, relatively fit, not reliant on dialysis and was even in the process of investigating a live transplant from their partner.
Our client had previously discussed with their family not to accept a higher risk transplant, and therefore had our client been armed with the full information, they would not have not gone ahead, and not suffered the infection and subsequent organ removal.
A serious incident investigation concluded that the incident represented ‘an example of donor transmitted infection’ which ‘contributed to the loss of one kidney graft and the death of a liver recipient.’ It said ‘The infection of the graft may have arisen during the removal procedure.’
Reflecting on the compensation award, the patient added:
This whole issue has had a huge impact on my life and my ability to work, so the money is needed and will be needed if I have to go back on dialysis again in the future.
I’d like to think lessons will be learned but I don’t feel there are enough repercussions for matters like this and the surgeons involved.
For them, the matter is over now and they move on. It’s not for me, and not for others affected also.
In statements printed in the media today relating to the case, Professor Meghana Pandit, chief medical officer at Oxford University Hospitals NHS Foundation Trust, apologised to the patient who accepted the kidney, adding:
This is a very unusual circumstance and we are keen to ensure that we do everything we can to make sure it doesn’t happen again in future.
John Forsythe, of NHS Blood and Transplant, said:
We acted quickly to investigate what happened and we worked with transplant centres afterwards.
