16.03.2015
Jim Stuart, aged 67, and Darren Hughes, 42, had kidney transplants in November 2013 at the University Hospital Of Wales but, after surgery, their conditions begun to deteriorate rapidly. The men lost consciousness and died just over two weeks later.
An inquest in December found that both men died from an infection of the brain called meningo-encephalitis, caused by a parasite halicephalobus which lives in the soil and is commonly found in horses. The donor of the kidneys also died from the same infection, which has only been diagnosed in five people worldwide and has proved fatal in each case.
Both families are being supported by specialist medical negligence lawyers at Irwin Mitchell in their bid to establish what went wrong in their loved ones’ cases and whether more could have been done to prevent their deaths.
And today, the families’ expert lawyer, Julie Lewis, urged Cardiff and the Vale University Health Board and the NHSBT to implement nationwide a series of recommendations contained within a Regulation 28 report from the coroner to the hospital’s Chief Executive, which is designed to prevent future deaths.
The report from, Acting Coroner Christopher Woolley urged the Trust to address the following:
• The core donor data form could have contained more information as to the results of the tests performed on the donor;
• There was information available on the medical microbiology report which was not passed on to the accepting transplant centre;
• The kidneys were accepted by the transplant centre over the telephone and not via the computer system;
• The kidneys were accepted by the consultant acting alone – the coroner recommends that the acceptance process should be made by a team as it is the most informed method of decision making;
• A standard consent form is used for all operations and after evidence heard at the inquest, this has been proved to be an unsatisfactory method. The forms should be redesigned.
“An organ transplant is a life-saving procedure and even though we are completely devastated after losing Darren in the manner we did, we want to make sure that no one is put off from accepting an organ from a donor as it is an essential and life-changing treatment for hundreds of patients each year.”
Judith Stuart, Jim’s widow said: “After reading the Coroner’s recommendations, I am pleased that he has highlighted a number of areas where he suggests that processes and procedures are changed in the future to prevent any other needless deaths.
“We want to highlight that every patient who is waiting for organs on the transplant list has the right to turn down an organ if they are concerned about the risks. We also feel it is important to say that every patient and family has the right to question the surgeon’s opinion and ask for more information.
“We feel that we weren’t given the opportunity to make an informed decision as we were not given any information. If we had been given a chance to consider the options about the surgery the outcome would have been entirely different.”
Evidence heard at the inquest was presented by a number of different organisations including investigations by University Hospital of Wales, NHS Blood and Transplant, Public Health England and Public Health Wales. They raised issues including:
• At the time of accepting the kidney for donation no organism responsible for the meningo-encephalitis had been identified;
• The surgeon did not consult a microbiologist or any other members of the team before deciding whether to accept the kidneys for transplantation;
• Both families gave evidence that they were not told about the specific risks involved in accepting these particular kidneys for transplantation; if they had been told the kidneys would have been refused;
• Several instances where National guidelines were not followed.
Transplanted Kidneys Were Infected With Parasitic Worms
Medical negligence lawyers at Irwin Mitchell representing the families of two men who died after being given kidneys infected with parasitic worms while undergoing transplants have called for recommendations by the Coroner investigating their deaths to be implemented nationwide to prevent future tragedies.Jim Stuart, aged 67, and Darren Hughes, 42, had kidney transplants in November 2013 at the University Hospital Of Wales but, after surgery, their conditions begun to deteriorate rapidly. The men lost consciousness and died just over two weeks later.
An inquest in December found that both men died from an infection of the brain called meningo-encephalitis, caused by a parasite halicephalobus which lives in the soil and is commonly found in horses. The donor of the kidneys also died from the same infection, which has only been diagnosed in five people worldwide and has proved fatal in each case.
Both families are being supported by specialist medical negligence lawyers at Irwin Mitchell in their bid to establish what went wrong in their loved ones’ cases and whether more could have been done to prevent their deaths.
And today, the families’ expert lawyer, Julie Lewis, urged Cardiff and the Vale University Health Board and the NHSBT to implement nationwide a series of recommendations contained within a Regulation 28 report from the coroner to the hospital’s Chief Executive, which is designed to prevent future deaths.
The report from, Acting Coroner Christopher Woolley urged the Trust to address the following:
• The core donor data form could have contained more information as to the results of the tests performed on the donor;
• There was information available on the medical microbiology report which was not passed on to the accepting transplant centre;
• The kidneys were accepted by the transplant centre over the telephone and not via the computer system;
• The kidneys were accepted by the consultant acting alone – the coroner recommends that the acceptance process should be made by a team as it is the most informed method of decision making;
• A standard consent form is used for all operations and after evidence heard at the inquest, this has been proved to be an unsatisfactory method. The forms should be redesigned.
Ian Hughes, Darren’s father, said: “We are pleased that the Coroner has taken the time to consider the factors that led up to Darren’s death and as a family we hope that his recommendations are taken into consideration by the Health Board and the Transplant services to make sure that this can never happen again.Expert Opinion
Both families are dealing with a truly heart-breaking and unimaginable ordeal and the inquest at the end of last year provided them with some of the answers about the deaths of their loved ones.
“We welcome the Coroner’s recommendations, which are designed to prevent future similar deaths. It is vital that lessons are learnt from these tragic deaths. Improvements should now be made by the NHS Blood and Transplant services as well as the Hospital to ensure that guidelines and protocol are thoroughly followed and abided to ensure that this cannot happened again
“These two people were hoping for a new lease of life by being given a kidney transplant but both of their lives were tragically cut short due to being given infected organs.
“There may be a place for the use of higher risk organs where a potential recipient is facing immediate death but dialysis is an alternative to transplantation and some individuals may be able to enjoy a good quality of life without surgery. The really important message is that patients must be given all of the relevant information so that they can make a decision as to whether they want to proceed with transplantation of a higher risk organ or accept the risk of remaining on dialysis.”
Julie Lewis - Partner
“An organ transplant is a life-saving procedure and even though we are completely devastated after losing Darren in the manner we did, we want to make sure that no one is put off from accepting an organ from a donor as it is an essential and life-changing treatment for hundreds of patients each year.”
Judith Stuart, Jim’s widow said: “After reading the Coroner’s recommendations, I am pleased that he has highlighted a number of areas where he suggests that processes and procedures are changed in the future to prevent any other needless deaths.
“We want to highlight that every patient who is waiting for organs on the transplant list has the right to turn down an organ if they are concerned about the risks. We also feel it is important to say that every patient and family has the right to question the surgeon’s opinion and ask for more information.
“We feel that we weren’t given the opportunity to make an informed decision as we were not given any information. If we had been given a chance to consider the options about the surgery the outcome would have been entirely different.”
Evidence heard at the inquest was presented by a number of different organisations including investigations by University Hospital of Wales, NHS Blood and Transplant, Public Health England and Public Health Wales. They raised issues including:
• At the time of accepting the kidney for donation no organism responsible for the meningo-encephalitis had been identified;
• The surgeon did not consult a microbiologist or any other members of the team before deciding whether to accept the kidneys for transplantation;
• Both families gave evidence that they were not told about the specific risks involved in accepting these particular kidneys for transplantation; if they had been told the kidneys would have been refused;
• Several instances where National guidelines were not followed.
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