Coroner Finds That Death Would Have Been Prevented

The wife of an organ transplant patient who died shortly after the procedure at Churchill Hospital in Oxford last year has called for lessons to be learned after the inquest into his case highlighted a series of fundamental failures in his care.

Leigh Robbins, from Sleaford, passed away aged 53 in March 2016 less than three months after the operation to transplant a pancreas.

The Assistant Coroner for Oxfordshire recorded a narrative conclusion at the end of the three-day inquest held at Oxford Coroner’s Court this week, confirming that Leigh had died from complications of cytomegalovirus (CMV), an infection he had developed as a result of undergoing the transplant.  The Court heard evidence that Leigh had suffered as a result of a series of failings in his care including:

• A mix-up of blood samples belonging to two organ donors when Leigh’s donor organ was tested which led to the donor organ being confirmed as negative for CMV infection, where in fact the organ had been positive for CMV;
• Failures by a series of healthcare professionals at post-transplant outpatient clinics to act upon blood test results which were positive for CMV infection, although a low level;
• Failures by doctors to take action to investigate the earlier positive CMV blood test result when he was readmitted to Churchill Hospital when he was unwell and in pain

Professor Masterton, a consultant microbiologist giving expert evidence to the inquiry, revealed that the kind of mix-up that had occurred at the donor testing stage should never happen and that had Leigh received adequate treatment the transplant would have gone ahead with the necessary anti-viral drugs and he would have survived.

He criticised the care that was provided at the outpatient clinics and on re-admission to hospital and said the blood test should have been repeated.   This would have led to the diagnosis and treatment of the CMV infection and, again, Leigh would have survived.

The Court heard evidence that Oxford University Hospitals NHS Foundation Trust, NHS Blood and Transplant and Public Health England had all undertaken thorough investigations which identified failings and had all taken a number of steps to prevent similar errors occurring in the future.

Despite this, the Coroner will now write to the Trust and organisations involved in the transplant process to clarify whether more can and should be done to prevent a re-occurrence.

Following Leigh’s death, his wife Rebecca instructed specialist medical negligence lawyers at Irwin Mitchell to investigate the circumstances surrounding his death and help her gain answers regarding whether it could have been prevented.

Guy Forster, the legal expert in Irwin Mitchell’s medical negligence team who is representing Rebecca, said: 

Expert Opinion

“The series of failings that have been revealed as part of our investigations and at the inquest itself have raised a number of very serious concerns in relation to both the systems in place and treatment provided to Leigh.

“It is to the credit of the organisations involved that they have undertaken thorough investigations and recognised at an early stage that action needs to be taken to tighten up the procedures in place and, following the conclusion of the hearing, we are reiterating our determination to ensure that all is done that can be done.

“There can be little doubt that Leigh was badly let down and several opportunities were missed to prevent his death. The last thing that the family want, however, is for there to be a loss of confidence in the transplant service; errors such as these are thankfully very rare and, tragically, all the evidence we have heard is that with adequate treatment Leigh’s transplant would have been successful and would have enhanced his quality of life.” Guy Forster - Partner

Rebecca Robbins, 37, said: “We are all hugely concerned by the findings of the inquest and it is devastating to know that, if things had been done differently, Leigh’s death could have potentially been prevented.

“Whilst nothing will ever be able to change what has happened, our only hope as a family now is that lessons can be learned to ensure that no one else faces the failings that led to Leigh’s death.

“We put huge faith and trust into the health service to ensure that Leigh got the quality, safe care he deserved and we are devastated by what happened. It simply cannot be allowed to happen again.”

Leigh was accepted for a transplant at Churchill Hospital in January 2016 following complications of an autoimmune disease. The donor organ had been reported as negative for a serious but common infection, CMV.  Leigh was also negative for CMV infection.  The procedure went well and he was discharged, albeit with the requirement of attending a weekly clinic.

At a clinic on 20 January 2016, the doctor ordered a series of blood tests.  The test was reported and seen on 23 January 2016 when it was found to be weakly positive of a CMV infection. It was not recognised that a positive test was an unusual and potentially concerning finding for a patient who was negative for CMV and who had received a CMV negative organ.

Tragically the test was not acted upon when in fact it should have been repeated.  At further outpatient appointments on 27 January and 3 February 2016 the test result was not acting upon.  Rebecca Robbins also gave evidence that he was becoming unwell and had developed a rash.

He was eventually transferred back to Churchill Hospital in early February, where he was investigated for pancreatitis and then for bleeding at the site of the transplant. It was not until his condition deteriorated later in February that a full septic screen was undertaken and CMV was diagnosed and anti-viral treatment was started.

Initially he responded to treatment but sadly his condition deteriorated and he passed away on 31 March 2016.

An internal investigation was undertaken by the Hospital Trust which recognised failures in care but it was not until NHS Blood and Transplant were asked to retest the original donor samples that it was recognised several months later that the donor had in fact been positive for CMV and had been reported as negative in error.  

A joint investigation by NHSBT and Public Health England discovered that there had been two donor patients processed in the laboratory simultaneously and the results of the patients had been switched, although an investigation was unable to determine when the switch occurred.