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Patient died after surgeon failed to disclose 'spilling contents of donor stomach' while removing organs
21 November 2019, 15:54
A patient died and two others fell ill after a surgeon failed to disclose that he had spilled the contents of a donor stomach while removing organs to use in transplants.
The surgeon, from Oxford University Hospital NHS Foundation Trust, accidentally cut the donor stomach but the incident was not recorded.
Several organs became infected with Candida albicans, a type of fungal infection, and were then transplanted into three patients.
One recipient, a 36-year-old, died of an aneurysm caused directly by infection from the donated liver.
A second patient, a 25-year-old with children, became life-threateningly ill and needed their transplanted kidney removed.
A third patient, aged 44, who received a combined kidney and pancreas transplant, fell ill but subsequently recovered.
The incident was only discovered 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 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 is from South Wales, needed the donor kidney removing as an emergency after suffering extreme pain and extensive internal bleeding.
They were put in an induced coma and needed 16 blood transfusions. They also ended up on dialysis for more than a year, despite not having needed it previously.
A "serious incident" report by NHS Blood and Transplant said the transplant surgeon from Oxford "had no recollection of anything of note during the retrieval", which took place in August 2015.
However, "upon reflection", he said a "small nick" had been caused to the donor's stomach during the procedure, and a "small volume of stomach content was spilt".
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 25-year-old took legal action against Oxford University Hospital NHS Foundation Trust, where the surgeon is still employed, and the NHS has agreed damages of more than £215,000.
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 patient who sued has now been left with life-limiting problems as a result of the mistake, including nerve damage linked to the removal of the infected kidney.
They also suffer pains in their legs and feet and have high blood pressure.
The patient 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.
"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.
"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."
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."