One NHS patient died and another became seriously ill after they received infected organs following a surgical blunder.
A senior doctor at Oxford University Hospital NHS Foundation Trust accidentally cut the donor’s stomach during the original procedure.
However, the unidentified surgeon did not tell officials as he should have done. The incident – which happened four years ago – was never recorded.
Several organs – which went to three patients – became infected with a fungus called Candida albicans, which can kill the vulnerable.
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 parent with children, became life-threateningly ill and needed their transplanted kidney removed.
They took legal action against the trust, where the surgeon is still employed. Health bosses have agreed to pay damages of more than £215,000 ($277,500).
A third patient, aged 44, who received a combined kidney and pancreas transplant, fell ill but subsequently recovered.
A doctor at Oxford University Hospital NHS Foundation Trust accidentally cut the donor’s stomach during the original procedure. However, the unidentified surgeon did not tell officials as he should have done. The incident – which happened four years ago – was never recorded
None of the patients have been identified. The shocking ordeal, which took place in August 2015, was uncovered by the Press Association news agency.
It is unclear whether the family of the 36-year-old who died or the 44-year-old are aware of the incident.
The incident only came to light after surgeons at Cardiff & Vale University Health Board sounded the alarm.
Medics at University Hospital of Wales, who were caring for the 25-year-old, were concerned that he became seriously ill and in agony after the transplant.
The patient, who does not wish to be named but is from South Wales, needed the donor kidney removing as an emergency.
They were put in an induced coma and needed 16 blood transfusions to keep him alive, after he suffered extensive internal bleeding.
The patient, who had moderate kidney failure, 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’.
Upon reflection, he admitted there was a ‘small nick’ to the donor’s stomach during the procedure. A small amount of content was spilt.
The spill was not admitted at the time of the procedure, meaning recipients of the organs and their doctors were unaware of the risk of infection.
The NHSBT report said the incident ‘represents an example of donor-transmitted infection with Candida albicans’.
It added that it contributed to the loss of one kidney graft and the death of a liver recipient.
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.
Lawyers representing the trust claimed the risk would have been considered low – even if known the mishap was known at the time of transplant.
But the patient’s solicitor Jodi Newton, a medical negligence specialist at Hudgell Solicitors, said it was ‘a completely unacceptable breach of duty of care’.
She added: ‘No matter what the outcome had been in this case, the failure to ensure that everybody involved… was reckless on the part of the surgeon.
‘It denied all involved, from the patients to the surgeons transplanting the organs, the knowledge of the full facts. It cannot be excused at any level.’
The patient who sued has life-limiting problems as a result of the mistake, including nerve damage linked to the removal of the infected kidney.
The patient – who has children – also suffer pains in their legs and feet and have high blood pressure.
They 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.
‘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.
She added: ‘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 the 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.’
Candida albicans is carried in the digestive system of all humans. However, it is entirely harmless unless it grows out of control.
It can cause infections if it enters the blood or internal organs such as the kidney, heart, or brain, the Center for Disease Control and Prevention says.
Mr Forsythe added that there is the possibility of it being spread when a surgeon retrieves abdominal organs.
NHSBT said that it was up to individual transplant centres to inform patients about contamination.