A patient died after being given an organ which was contaminated when a surgeon accidentally cut the donor’s stomach, an investigation found.
The 36-year-old was among three patients who became ill upon being given infected organs after the doctor failed to declare the incident at the time which took place in Wales involving a surgeon from Oxford University Hospital NHS foundation trust.
As a result of the blunder, several organs were infected with Candida albicans, a type of fungal infection. As no one was alerted, three patients then received organs, costing one their life, an incident report revealed.The 36-year-old died of an aneurysm caused by an infection from the donated liver. A second patient, a 25-year-old, needed their transplanted kidney removed. A third patient, aged 44, who had a kidney and pancreas transplant, also fell ill.
The incident only came to light after surgeons at Cardiff and Vale University Health Board raised the alarm with the Human Tissue Authority and the Welsh Government. They became concerned when the 25-year-old under their care at the University Hospital of Wales became seriously ill. The patient was put in an induced coma, needed 16 blood transfusions and ended up on dialysis.
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” in August 2015. But “upon reflection”, he said a “small nick” in the donor’s stomach had led to a “small volume of stomach content” being spilt.
The spill was not documented or admitted at the time meaning those receiving the organs and their doctors were unaware of the risk of infection.
The 25-year-old sued the Oxford trust, where the surgeon is still employed. The trust admitted breaching its duty of care and agreed to pay £215,000 in damages.
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.”
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.”
It was unclear if the family of the 36-year-old who died or the 44-year-old were aware of the incident.