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| Patient died after 'transplant surgeon error' | |
| (about 2 hours later) | |
| A transplant patient died after a surgeon failed to disclose he had spilt stomach contents on organs which went on to be used in NHS operations. | A transplant patient died after a surgeon failed to disclose he had spilt stomach contents on organs which went on to be used in NHS operations. |
| The 36-year-old died of an aneurysm caused directly by infection from a donated liver, while two other patients became ill from transplants. | The 36-year-old died of an aneurysm caused directly by infection from a donated liver, while two other patients became ill from transplants. |
| The incident took place in 2015 but only came to light when one of the sick patients attended a hospital in Wales. | |
| It had involved a surgeon from Oxford University NHS Foundation Trust. | |
| The trust has agreed damages of £215,000 for one of the cases. | The trust has agreed damages of £215,000 for one of the cases. |
| Several organs became infected with Candida albicans, a fungal infection, after the surgeon cut the stomach in a donor while retrieving organs, spilling the contents over other organs. | Several organs became infected with Candida albicans, a fungal infection, after the surgeon cut the stomach in a donor while retrieving organs, spilling the contents over other organs. |
| The surgeon did not tell anyone as he should have done and the organs were transplanted into three patients. | The surgeon did not tell anyone as he should have done and the organs were transplanted into three patients. |
| One recipient died after receiving an infected liver, while a 44-year-old received a kidney and pancreas and a 25-year-old parent from Wales received a kidney. | One recipient died after receiving an infected liver, while a 44-year-old received a kidney and pancreas and a 25-year-old parent from Wales received a kidney. |
| The incident only came to light after surgeons at Cardiff & Vale University Health Board raised the alarm with the Human Tissue Authority and the Welsh Government. | The incident only came to light after surgeons at Cardiff & Vale University Health Board raised the alarm with the Human Tissue Authority and the Welsh Government. |
| They became worried when the 25-year-old patient who received the kidney, and who was under their care at the University Hospital of Wales, became seriously unwell due to the infected organ. | They became worried when the 25-year-old patient who received the kidney, and who was under their care at the University Hospital of Wales, became seriously unwell due to the infected organ. |
| The patient, who does not wish to be named but is from south Wales, needed the donor kidney removing as an emergency after suffering extreme pain and extensive internal bleeding. | The patient, who does not wish to be named but is from south Wales, needed the donor kidney removing as an emergency after suffering extreme pain and extensive internal bleeding. |
| The 25-year-old was placed in an induced coma and given 16 blood transfusions, before spending a year on dialysis having never needed it before. | The 25-year-old was placed in an induced coma and given 16 blood transfusions, before spending a year on dialysis having never needed it before. |
| Risk of infection | Risk of infection |
| The Oxford University trust has paid £215,000 in damages to the patient after they launched a legal challenge. | The Oxford University trust has paid £215,000 in damages to the patient after they launched a legal challenge. |
| A serious incident report by NHS Blood and Transplant (NHSBT) said the surgeon had "no recollection of anything of note" when taking the organs, but had noticed a "small nick" on reflection which saw a small amount of stomach content spilt. | A serious incident report by NHS Blood and Transplant (NHSBT) said the surgeon had "no recollection of anything of note" when taking the organs, but had noticed a "small nick" on reflection which saw a small amount of stomach content spilt. |
| The spill was not documented at the time of the procedure, meaning those receiving the organs and their doctors were unaware of the risk of infection. | The spill was not documented at the time of the procedure, meaning those receiving the organs and their doctors were unaware of the risk of infection. |
| The NHSBT report concluded: "This incident represents an example of donor-transmitted infection with Candida albicans which contributed to the loss of one kidney graft and the death of a liver recipient. | The NHSBT report concluded: "This incident represents an example of donor-transmitted infection with Candida albicans which contributed to the loss of one kidney graft and the death of a liver recipient. |
| "The infection of the graft may have arisen during the retrieval procedure." | "The infection of the graft may have arisen during the retrieval procedure." |
| The trust admitted it had been in breach of duty of care by the failure of the surgeon to record the cut into the donor's stomach. | The trust admitted it had been in breach of duty of care by the failure of the surgeon to record the cut into the donor's stomach. |
| 'The surgeon wasn't honest' | 'The surgeon wasn't honest' |
| In defence of the legal action, trust lawyers claimed that, despite the stomach spill, even if known at the time of transplant, the risk would have been considered low. | In defence of the legal action, trust lawyers claimed that, despite the stomach spill, even if known at the time of transplant, the risk would have been considered low. |
| But solicitor Jodi Newton, a medical negligence specialist at Hudgell Solicitors, representing the patient, said it was "a completely unacceptable breach of duty of care" which was "extremely damaging for patient trust in surgeons". | But solicitor Jodi Newton, a medical negligence specialist at Hudgell Solicitors, representing the patient, said it was "a completely unacceptable breach of duty of care" which was "extremely damaging for patient trust in surgeons". |
| The patient, who did not want to be named, said: "What angers me to this day is that fact that the surgeon who removed the organs from the donor wasn't honest. | The patient, who did not want to be named, said: "What angers me to this day is that fact that the surgeon who removed the organs from the donor wasn't honest. |
| "It was only when people who received the organs became unwell that the truth was told." | "It was only when people who received the organs became unwell that the truth was told." |
| Prof Meghana Pandit, chief medical officer at Oxford University Hospitals NHS Foundation Trust, said: "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." | Prof Meghana Pandit, chief medical officer at Oxford University Hospitals NHS Foundation Trust, said: "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, medical director for organ donation and transplantation at NHSBT, said: "Our thoughts are with the recipients and their families over this sad and unusual case. | John Forsythe, medical director for organ donation and transplantation at NHSBT, said: "Our thoughts are with the recipients and their families over this sad and unusual case. |
| "We acted quickly to investigate what happened and we worked with transplant centres afterwards. Our report concluded the infection of the transplanted organ may have arisen during the retrieval procedure." | "We acted quickly to investigate what happened and we worked with transplant centres afterwards. Our report concluded the infection of the transplanted organ may have arisen during the retrieval procedure." |
| It is unclear whether the families of the 36-year-old who died or the 44-year-old are aware of the incident. | It is unclear whether the families of the 36-year-old who died or the 44-year-old are aware of the incident. |
| NHSBT said it was up to local transplant centres to inform patients about contamination. | NHSBT said it was up to local transplant centres to inform patients about contamination. |