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NHS apologises after patients received kidneys from donor with cancer NHS admits negligence after patients received cancerous kidneys
(about 3 hours later)
The NHS has admitted negligence in giving two transplant patients kidneys from a donor with a rare and aggressive form of cancer.The NHS has admitted negligence in giving two transplant patients kidneys from a donor with a rare and aggressive form of cancer.
The incident at the Royal Liverpool University hospital involved organs from a woman who died at another hospital and was later found to have intravascular B-cell lymphoma. The patients involved were told days after their transplants in November 2010 and each needed six cycles of chemotherapy. The incident at the Royal Liverpool University hospital involved organs from a woman who died at another hospital and was later found to have had a cancer known as intravascular B-cell lymphoma.
Compensation has still to be agreed but NHS Blood and Transplant (NHSBT) the body overseeing abut 3,750 organ transplants a year in the UK, said the incident involved human error by a specialist nurse. The patients involved were told days after their transplants in November 2010 and each needed six cycles of chemotherapy. Both were told after that treatment there was no sign of the cancer. They will undergo further scans next month.
Lynda Hamlyn, its chief executive, offered "sincere and unreserved apologies" to Robert Law and Gillian Smart, saying each received a donated kidney that would have been rejected by their surgeon if he had been aware of the complete donor information. Compensation has still to be agreed but NHS Blood and Transplant (NHSBT), the body overseeing about 3,750 organ transplants a year in the UK, said the incident included human error by a specialist nurse who had not completed her training, but was receiving support from a colleague. Lynda Hamlyn, its chief executive, offered "sincere and unreserved apologies" to Robert Law and Gillian Smart, saying each received a donated kidney that would have been rejected by their surgeon if he had been aware of the complete donor information.
Both Law and Smart said that they wanted lessons learned from the incident but thousands of others needing transplants should not be deterred. Law, 60, hoped the circumstances surrounding the incident would be disclosed publicly. The admission of liability from NHSBT to the patients' lawyers states that there was a failure to communicate to the transplant team at the Liverpool hospital the "possibility" that the donor had lymphoma and that the transplant would not have gone ahead if this had been known. It does not say that the transplanted kidneys were cancerous. The lawyers say they were.
"Revealing how this was allowed to happen would ensure that medical professionals throughout the UK can learn from the mistakes made and ensure better care in the future," said Law, a divorced father of four children from Wirral, Merseyside. Both Law and Smart said that they wanted lessons to be learned from the incident but thousands of others needing transplants should not be deterred. Law, 60, hoped the circumstances surrounding the incident would be disclosed publicly.
"Revealing how this was allowed to happen would ensure that medical professionals throughout the UK can learn from the mistakes made and ensure better care in the future," said Law, a father of four from Wirral, Merseyside.
"I also feel strongly that the NHS trusts involved should publish a comprehensive report stating what measures have been taken to minimise the risk of a tragic recurrence.""I also feel strongly that the NHS trusts involved should publish a comprehensive report stating what measures have been taken to minimise the risk of a tragic recurrence."
Law, who launched a claim against the NHS in March last year, said: "The renal unit (at the Royal Liverpool) says my kidney is working well. However, I am still feeling the effects from the chemotherapy and medications which I now take. Over the last 15 months I have suffered in many ways, physically and mentally, including weight gain, muscle wastage and depression. Law, who launched legal action in March last year, said: "The renal unit [at the Royal Liverpool] says my kidney is working well. However, I am still feeling the effects from the chemotherapy and medications which I now take. Over the last 15 months I have suffered in many ways, physically and mentally, including weight gain, muscle wastage and depression."
"Of course, I am encouraged that the NHSBT has admitted negligence but to blame one specialist nurse seems very, very strange when there are probably 20-30 people involved in the transplant. My one aim was to establish what happened and what measures were in place to stop it happening again." Law said more than 10,000 people needed a transplant, and three people a day would die waiting, as there were not enough organs available, he said. "I am so grateful to the family of the donor who made a courageous decision at an extremely difficult time."
Law had continued to campaign and support organ donation throughout the "gruelling episode". More than 10,000 people needed a transplant, and three people a day would die waiting, as there were not enough organs available, he said. "I am so grateful to the family of the donor who made a courageous decision at an extremely difficult time." Smart, 47, from St Helens, Merseyside, who is married and has two teenage children, had been diabetic 30 years before the operation. She said: "I felt devastated to learn that I had received a kidney infected with cancer. The result has been psychologically and physically draining.
Smart, 47, from St Helens, Merseyside, who is married and has two teenage children, had been diabetic 30 years before the operation. She said: "I felt devastated to learn that I had received a kidney infected with cancer. The result has been psychologically and physically draining." "Before the chemo and everything I was dress size 12, now I am a 22. My hair has grown back brunette, I was blonde before"
Sue Taylor, Law's lawyer at Manchester solicitors JMW, said the admission from NHSBT was "a major milestone" in the case but he and the public needed assurances lessons had been learned. Sue Taylor, Law's lawyer at Manchester solicitors JMW, said: "For anyone else to have to go through such a terrible ordeal would be an absolute travesty and that has been at the forefront of Mr Law's mind throughout."
"For anyone else to have to go through such a terrible ordeal would be an absolute travesty and that has been at the forefront of Mr Law's mind throughout."
Smart's solicitor, John Kitchingman, of lawyers Pannone, said she recognised that what happened was "a result of a number of rare but nevertheless preventable occurrences".Smart's solicitor, John Kitchingman, of lawyers Pannone, said she recognised that what happened was "a result of a number of rare but nevertheless preventable occurrences".
Hamlyn of NHSBT said: "The cause of the mistake was human error which was dreadful for all concerned but lessons have been learned through an extensive investigation and a number of changes to working practices have been implemented to help prevent any such event happening again. Hamlyn of NHSBT said: "The cause of the mistake was human error which was dreadful for all concerned. I do not underestimate how traumatic this has been for those involved but lessons have been learned through an extensive investigation and a number of changes to working practices have been implemented to help prevent any such event happening again."
"Maintaining the safety of organ donations is of vital importance and I would stress that we do everything we can to make sure that all donated organs are as fit as possible for transplant. Every transplant recipient should be given information by their surgeon about the risks associated with the transplantation, said Hamlyn but "no second-hand organ can ever be completely risk free."
"However, every transplant recipient should also be given information by their surgeon about the risks associated with the transplantation. No second-hand organ can ever be completely risk-free. In a separate statement, the service said :"All our specialist nurses in organ donation (or SN-ODs) are experienced nurses who come from a background in intensive care or accident and emergency. However in this particular case, the SN-OD had been in the role for a relatively short period of time; her training was not complete but she was receiving support from a colleague."
"I do not underestimate how traumatic this has been for those involved, but for the sake of those needing a life-saving transplant I would urge people to discuss their wishes for donation with their family and join the NHS organ donor register." The incident happened weeks before new guidance was circulated to clinicians on obtaining consent from patients and warning them of risks – including from donor-donated tumours.
NHSBT has previously told the Guardian the incident happened weeks before new guidance was circulated to clinicians on obtaining consent from patients and warning them of risks – including from donor-donated tumours. Improved communication and co-ordination has been ordered between the transplant service and surgeons and staff in different hospitals. Pending a new electronic system that will become mandatory, all verbal offers by specialist nurses must be recorded and backed up in writing.
Improved co-ordination has also been ordered between the transplant service and surgeons and staff in different hospitals. The service is compiling a national register of such incidents. The NHSBT has previously warned that postmortems on donors before transplantation are impossible as they would take too long and render organs unusable, and that most lymphomas could not be detected by blood tests.
The admission of liability from NHSBT to the patients' lawyers states that there was a failure to communicate to the transplant team at the Liverpool hospital the "possibility" that the donor had lymphoma and that the transplant would not have gone ahead if this had been known. It does not, however, say that the transplanted kidneys were cancerous. Both lawyers say, however, the organs were. The service is though now asking for pathologists performing autopsies on donors for coroners to alert transplant bosses quickly to any finding that might affect the health and welfare of organ or tissue recipients.