14 Aug 2019 David John Smith · Prevention of Future Deaths report Manchester City
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Concerns raised 1
Failure to transmit donor kidney CMV status to the renal transplant team View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
David John Smith · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David John Smith underwent a dual renal transplant involving kidneys from a CMV-positive donor, but the donor’s CMV status was not communicated to him and was incorrectly recorded as negative. He did not receive CMV prophylaxis, later developed CMV infection and ganciclovir resistance, deteriorated, and died on 5 July 2017. The principal concerns were the consent process and failures to communicate and accurately record the donor’s CMV status.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to transmit donor kidney CMV status to the renal transplant team
Wider context from the report “1. The consent process – I found that the CMV status of the donor’s kidneys (listed as positive on the Electronic Offering System form) was never communicated to the Deceased for him to consider the risks of proceeding with the transplantation, and for him to provide informed consent.
2 Recording of the CMV status – When the plan for the deceased’s surgery was communicated to the Renal transplant team in an email, this did not include reference to the donor’s CMV status, nor did it attach the relevant EOS form . Consideration should be given to introducing a process in which the EOS form itself is sent onwards to the Renal transplant team to ensure important information such as the CMV status is not missed by the treating clinicians.
” Source location David John Smith · Prevention of Future Deaths report
Open source report
Concerns raised 3
Failure to ensure identification and electronic transmission of recent radiological evidence View source Failure to identify and transfer key clinical information to receiving teams View source Failure to ensure identification and transfer of key referral information View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Leeds Teaching Hospitals NHS Trust Mid Yorkshire Teaching NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Mid Yorkshire Teaching NHS Trust
Distribute further promotion of electronic systems and processes for transferring imaging and clinical data through local multidisciplinary teams.
View source
Mid Yorkshire Teaching NHS Trust
Participate in the Regional Imaging Collaborative to improve interoperability and image transfer between acute provider organisations across Yorkshire.
View source
Mid Yorkshire Teaching NHS Trust
Revise and publish the inter-provider transfer Standard Operating Procedure for cancer pathway handovers.
View source
Leeds Teaching Hospitals NHS Trust
Recirculate the updated pathway and highlight the need to complete referral forms fully and accurately.
View source See 1 more action
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AI-generated summary
Dorothy Cooper · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Dorothy Cooper underwent elective surgery on 29 September 2014, after which complications included splenic injury, liver ischaemia and infarction, and poor nutritional status. She later developed overwhelming sepsis and died in hospital on 6 January 2015. The principal concerns were incomplete information in a referral to the receiving team and inadequate procedures for identifying and following up gaps in the clinical history.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to ensure identification and electronic transmission of recent radiological evidence
Wider context from the report “During the course of the evidence it became clear that when Pinderfields Hospital (the Mid Yorkshire Hospital Trust) referred Mrs Cooper to the Leeds Hospitals Trust to investigate the possibility of a liver carcinoma, there was a failure to provide key Information to the receiving team. The information omitted related to blood tests, full radiological evidence and key stages in Mrs Cooper’s recent medical history. It was clear that had that information been provided, the clinical picture could have painted more towards an infective process having been responsible for Mrs Cooper’s condition rather than a cholangiocarcinoma and thus alternative management was indicated. The receiving team at Leeds identified in their first multi-disciplinary team meeting that there was insufficient information provided in team of clear clinical parameters but failed to proactively pursue this.
My concern that if there is not effective training for junior doctors completing the referral form and systems for ensuring that key information is identified and transferred to the receiving team, and also that the receiving team have systems in place for ensuring any gaps in the knowledge are filled, then patients will continue to be at risk in the future where management and treatment plans are devised on the basis of an incomplete clinical picture.
Matters of concern in summary are :
1. Inadequate training of junior doctors who complete referral forms.
2. A lack of understanding as to what key information is required in referrals of this nature.
3. Procedures for ensuring that all recent radiological evidence in matters of this nature is identified and electronically transmitted to the receiving team.
” Source location Dorothy Cooper · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to identify and transfer key clinical information to receiving teams
Wider context from the report “During the course of the evidence it became clear that when Pinderfields Hospital (the Mid Yorkshire Hospital Trust) referred Mrs Cooper to the Leeds Hospitals Trust to investigate the possibility of a liver carcinoma, there was a failure to provide key Information to the receiving team . The information omitted related to blood tests, full radiological evidence and key stages in Mrs Cooper’s recent medical history . It was clear that had that information been provided, the clinical picture could have painted more towards an infective process having been responsible for Mrs Cooper’s condition rather than a cholangiocarcinoma and thus alternative management was indicated. The receiving team at Leeds identified in their first multi-disciplinary team meeting that there was insufficient information provided in team of clear clinical parameters but failed to proactively pursue this.
My concern that if there is not effective training for junior doctors completing the referral form and systems for ensuring that key information is identified and transferred to the receiving team , and also that the receiving team have systems in place for ensuring any gaps in the knowledge are filled, then patients will continue to be at risk in the future where management and treatment plans are devised on the basis of an incomplete clinical picture.
Matters of concern in summary are :
1. Inadequate training of junior doctors who complete referral forms.
2. A lack of understanding as to what key information is required in referrals of this nature.
3. Procedures for ensuring that all recent radiological evidence in matters of this nature is identified and electronically transmitted to the receiving team.
” Source location Dorothy Cooper · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to ensure identification and transfer of key referral information
Wider context from the report “During the course of the evidence it became clear that when Pinderfields Hospital (the Mid Yorkshire Hospital Trust) referred Mrs Cooper to the Leeds Hospital Trust to investigate the possibility of a liver carcinoma, there was a failure to provide key Information to the receiving team. The information omitted related to blood tests, full radiological evidence and key stages in Mrs Cooper’s recent medical history. It was clear that had that information been provided, the clinical picture would have pointed more towards an infective process having been responsible for Mrs Cooper’s condition rather than a cholangiocarcinoma and thus alternative management was indicated. The receiving team at Leeds identified in their first multi-disciplinary team meeting that there was insufficient information provided in terms of clear clinical parameters but failed to proactively pursue this.
My concern is that it is not effective training for junior doctors completing the referral form and systems for ensuring that key information is identified and transferred to the receiving team , and also that the receiving team have systems in place for ensuring any gaps in the knowledge are filled, then patients will continue to be at risk in the future where management and treatment plans are devised on the basis of an incomplete clinical picture.
Matters of concern in summary are :
1. The absence of clear procedures for those in MDT meetings to proactively follow up inadequately completed referral forms.
2. Lack of procedures to proactively obtain information to complete gaps in clinical history
” Source location Dorothy Cooper · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Distribute further promotion of electronic systems and processes for transferring imaging and clinical data through local multidisciplinary teams.
Verbatim wording from the response “2. The electronic transfer of imaging and other clinical data to support specialist opinions is well embedded, and appears to have functioned adequately in this case. Further promotion of the systems and processes by which this can be achieved will be distributed through our local Mid Yorkshire MDT’s. (completion by end of January 2016)” Source location 2015-0412-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Participate in the Regional Imaging Collaborative to improve interoperability and image transfer between acute provider organisations across Yorkshire.
Verbatim wording from the response “3. The author would also like to make readers aware that a Regional Imaging Collaborative has just begun work to improve system interoperability and image transfer between acute provider organisations across Yorkshire. Both Leeds Teaching Hospitals and Mid Yorkshire Hospitals NHS Trusts are actively participating in that collaborative. (Project completion not expected until early 2017)” Source location 2015-0412-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise and publish the inter-provider transfer Standard Operating Procedure for cancer pathway handovers.
Verbatim wording from the response “The process of inter-provider transfer of care for patients on cancer pathways in West Yorkshire is being revised, collaboratively at present. Both The Mid Yorkshire Hospitals NHS Trust and The Leeds Teaching Hospitals NHS Trust are centrally involved in that improvement work. The main action to improve handover of cases like Mrs Cooper’s will be to embed the revised processes detailed in the Standard Operating Procedure being drafted subsequent to that review. We expect this will be embedded by the end of February 2016.” Source location 2015-0412-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Recirculate the updated pathway and highlight the need to complete referral forms fully and accurately.
Verbatim wording from the response “To reiterate the importance of submitting relevant clinical information, the Hepatobiliary MDT Co-ordinator has re-circulated the pathway document that was updated in October 2014 and highlighted the need for completion of the referral form as fully and accurately as possible.” Source location 2015-0412-Response2
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Electronic transfer of imaging and clinical data was well embedded and appears to have functioned adequately in this case.
Verbatim wording from the response “1. Through my regular clinical practice, and close working relationship with several of the MDT’s at Mid Yorkshire Hospitals, I am aware that the referral processes between local and specialist MDT’s at Leeds, are well embedded and this routinely includes transfer of imaging and pathology data. I have confirmed that the pertinent Mid Yorkshire radiological evidence (including reports) was transferred prior to the initial Leeds HPB MDT evaluation of this patient.” Source location 2015-0412-Response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The lack of clinical details did not influence the final diagnosis, treatment or outcome.
Verbatim wording from the response “The MDT has noted that you have raised concerns that they reviewed Mrs Cooper’s case at their MDT meeting without adequate clinical details. They wish to highlight the fact that they did make attempts to obtain the details by way of correspondence with Mid-Yorkshire NHS Trust (Pinderfields General Hospital). The team is clear however that the lack of details did not influence the final diagnosis, treatment or outcome.” Source location 2015-0412-Response2
Open published response
Concerns raised 4
Failure of systems to ensure capture and transmission of relevant donor information View source Lack of SN-OD certification of transmitted donor information when required View source Failure to transmit relevant medical microbiology information to the accepting transplant centre View source
Incomplete capture of donor lumbar test information View source See 1 more concern
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
NHS Blood and Transplant
Develop and implement an electronic system for specialist nurses to record and transmit donor data to transplant centres.
View source
NHS Blood and Transplant
Continue reminding specialist nurses to capture and provide key donor information accurately and fully during the interim period.
View source
NHS Blood and Transplant
Audit organ-donor primary records to assess the accuracy and completeness of transferring information from medical case notes to donor files and EOS.
View source
NHS Blood and Transplant
Share the case and its learning through specialist nurse, transplant surgeon and intensive care governance channels, including case-study presentations and NHSBT communications.
View source See 1 more action
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AI-generated summary
Robert James Stuart and Darren Llewellyn Hughes · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Robert James Stuart and Darren Llewellyn Hughes developed meningoencephalitis after receiving kidney transplants from the same donor and died on 17 and 19 December 2013 respectively. The infection was caused by a Halicephalobus nematode in the transplanted kidneys. Concerns included incomplete transmission of donor information, inadequate use of the EOS system and the need for a more multidisciplinary organ-acceptance process.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of systems to ensure capture and transmission of relevant donor information
Wider context from the report “Had this information been available to the accepting consultant ████████ then it may have caused more questions to be asked and aided in the acceptance process. The Coroner is concerned that NHSBT should employ systems to ensure the capture and transmission of all relevant information to the accepting transplant centre , and that SN-ODs should be in a position if required to certify that all relevant and available information has been transmitted.
” Source location Robert James Stuart and Darren Llewellyn Hughes · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of SN-OD certification of transmitted donor information when required
Wider context from the report “Had this information been available to the accepting consultant ████████ then it may have caused more questions to be asked and aided in the acceptance process. The Coroner is concerned that NHSBT should employ systems to ensure the capture and transmission of all relevant information to the accepting transplant centre, and that SN-ODs should be in a position if required to certify that all relevant and available information has been transmitted .
” Source location Robert James Stuart and Darren Llewellyn Hughes · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to transmit relevant medical microbiology information to the accepting transplant centre
Wider context from the report “(2) There was information available on the medical microbiology report which was not passed on to the accepting transplant centre.
” Source location Robert James Stuart and Darren Llewellyn Hughes · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Incomplete capture of donor lumbar test information
Wider context from the report “(1) The core donor data form could have contained more information as to the second lumbar test performed on the donor and could have given the results of the first lumbar puncture test.
” Source location Robert James Stuart and Darren Llewellyn Hughes · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and implement an electronic system for specialist nurses to record and transmit donor data to transplant centres.
Verbatim wording from the response “The NHSBT Board, at its January meeting, approved expenditure to change the way in which Specialist Nurses record and transmit data electronically to transplant centres. This will simplify the work of the nurses, reduce the risk of errors in recording the data in NHSBT systems and increase the amount of data transmitted to transplant centres via EOS. This is a major IT development and we” Source location 2014-0549-Response-by-NHS-Blood-Transport
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue reminding specialist nurses to capture and provide key donor information accurately and fully during the interim period.
Verbatim wording from the response “expect it to be fully operational by April 2016. In the interim period, we continue to remind the nurses of the importance of capturing and providing key information accurately and fully.” Source location 2014-0549-Response-by-NHS-Blood-Transport
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit organ-donor primary records to assess the accuracy and completeness of transferring information from medical case notes to donor files and EOS.
Verbatim wording from the response “As a direct result of this incident, NHSBT has commenced an audit in order to review the primary records for organ donors and to assess the accuracy and completeness of the transfer of information from medical case notes to the donor file / EOS. This audit tests the first stage of the donation process and will report on a monthly basis with quarterly and annual reviews. This audit is being undertaken with the cooperation of a number of NHS Trusts.” Source location 2014-0549-Response-by-NHS-Blood-Transport
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the case and its learning through specialist nurse, transplant surgeon and intensive care governance channels, including case-study presentations and NHSBT communications.
Verbatim wording from the response “Shared learning
This sad case has been shared widely with our specialist nurses in organ donation, as well as transplant surgeons and intensive care staff via the NHSBT governance structure. This has included a brief outline within a previous edition of ‘Cautionary Tales’, which is a method of sharing key cases with the wider transplant community. The decision was made to not include a full summary prior to the inquest as NHSBT did not wish to impact upon proceedings, but a full case review, together with learning points will now be included in the March 2015 edition.” Source location 2014-0549-Response-by-NHS-Blood-Transport
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Specialist nurses cannot certify that all relevant information was transmitted because data come through multiple systems, timescales, methods and treating clinicians.
Verbatim wording from the response “2) Specialist nurse certification of information” Source location 2014-0549-Response-by-NHS-Blood-Transport
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The microbiology results were unavailable before the transplant decision and therefore could not have affected the decision to transplant.
Verbatim wording from the response “2) Microbiology results
Your observations regarding the microbiology report are noted however NHSBT has obtained written confirmation from the independent testing reference laboratory that although the first blood sample taken at the donor hospital on 25th November 2013 was received for testing the same day, the enterovirus, parechovirus, HSV and VZV results were not available until 3rd January 2014. Additional tests of meningococcal and pneumococcal were requested as additional tests on the 2nd January 2014.” Source location 2014-0549-Response-by-NHS-Blood-Transport
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.