Patient killed by infected organ after surgeon's error
Oxford - A patient was killed and another nearly died after they received contaminated organ transplants due to a blunder by an NHS surgeon.
The surgeon was removing the kidneys, liver and pancreas of a donor when he accidentally cut the stomach – spilling its contents on to the other organs.
This meant they became infected with the fungal infection Candida albicans. However, the surgeon at Oxford University Hospitals NHS Foundation Trust failed to record the incident so the organs – meant for chronically ill patients – went on to be used.
They were transplanted into three patients. One, aged 36, died of an aneurysm caused directly by infection from the donated liver. A second, a 25-year-old parent with two young children, had an emergency operation to remove their transplanted kidney and has been left in ‘constant pain’. A third patient, 44, who had a combined kidney and pancreas transplant, fell ill but recovered.
The incident came to light only after surgeons at Cardiff & Vale University Health Board raised the alarm with the Human Tissue Authority and the Welsh government.
They acted after the 25-year-old patient, who was under their care at the University Hospital of Wales, ended up in a coma.
They needed 16 blood transfusions and are now "lucky to be alive". A "serious incident" report by NHS Blood and Transplant, obtained by the Press Association, said the transplant surgeon – who has not been identified – "had no recollection of anything of note during the retrieval" in August 2015.
However, "upon reflection" he admitted a "small nick" had been caused to the donor’s stomach, and a ‘small volume of stomach content was spilt’.
The spill was not documented or admitted at the time.
The 25-year-old patient, who did not want to be named, said: "What angers me is the fact the surgeon wasn’t honest. It was only when people who received the organs became unwell that the truth was told." The patient, who has been left with nerve damage and limb pain, took legal action against the Oxford trust, where the surgeon is still employed, and the NHS has agreed damages of more than £215 000.
Professor Meghana Pandit, chief medical officer at the trust, apologised to the patient, adding: "This is a very unusual circumstance and we are keen to ensure we do everything we can to make sure it doesn’t happen again."
It is unclear if the family of the patient who died or the 44-year-old who recovered are aware of the Oxford incident.
John Forsythe, a medical director at NHS Blood and Transplant, apologised and said they had ‘acted quickly’ to establish what had happened.Daily Mail