Recurring concern

Failure to reliably transfer complete information to transplant centres

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First reported 18 Dec 2014•Latest report 14 Aug 2019

Definition

What this concern includes

Includes failures in the dedicated process for identifying, transmitting, certifying, receiving or resolving gaps in clinically relevant information sent to an accepting transplant centre or comparable receiving specialist team, including donor information, medical history, laboratory results and radiological evidence.

Not included

Excludes generic clinical-record, communication or information-sharing deficiencies where no transfer to an accepting transplant centre or receiving specialist team is identified.
Excludes failures to interpret or act on complete information after it has been reliably received.
Excludes failures limited to the quality of donor selection, organ allocation or transplant treatment where information transfer is not the deficient control.
Excludes ordinary inter-service referrals without a material need to transfer complete information for specialist acceptance or treatment decisions.

Reports: 3
Individual concerns: 8
Date range: 2014–2019
Stated actions: 8

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Leeds Teaching Hospitals NHS Trust1

Manchester University NHS Foundation Trust1

Mid Yorkshire Teaching NHS Trust1

NHS Blood and Transplant1

University Hospital of Wales1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

14 Aug2019
Manchester City
Concerns raised1
1. Failure to transmit donor kidney CMV status to the renal transplant team
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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.

Read the report on judiciary.uk
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 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
Page 2 · concerns
Open source report
21 Oct2015
South Yorkshire (Eastern)
Concerns raised3
1. Failure to ensure identification and electronic transmission of recent radiological evidence
2. Failure to identify and transfer key clinical information to receiving teams
3. Failure to ensure identification and transfer of key referral information
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Distribute further promotion of electronic systems and processes for transferring imaging and clinical data through local multidisciplinary teams.
  Stated by Mid Yorkshire Teaching NHS TrustStated planned
2. Action
  Participate in the Regional Imaging Collaborative to improve interoperability and image transfer between acute provider organisations across Yorkshire.
  Stated by Mid Yorkshire Teaching NHS TrustStated in progress
3. Action
  Revise and publish the inter-provider transfer Standard Operating Procedure for cancer pathway handovers.
  Stated by Mid Yorkshire Teaching NHS TrustStated in progress
1. Action
  Recirculate the updated pathway and highlight the need to complete referral forms fully and accurately.
  Stated by Leeds Teaching Hospitals NHS TrustStated completed
Respondent positions 2
1. Position
  Electronic transfer of imaging and clinical data was well embedded and appears to have functioned adequately in this case.
  Stated by Mid Yorkshire Teaching NHS TrustDisputes the concern
1. Position
  The lack of clinical details did not influence the final diagnosis, treatment or outcome.
  Stated by Leeds Teaching Hospitals NHS TrustDisputes the concern
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.

Read the report on judiciary.uk
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 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
Page 2 · concerns
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
Page 2 · concerns
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
Page 2 · concerns
Open source report
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
Page 3 · response
Published 21 October 2015
Open published response
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
Page 3 · response
Published 21 October 2015
Open published response
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
Page 1 · response
Published 21 October 2015
Open published response
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
Page 3 · response
Published 21 October 2015
Open published response
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
Page 2 · response
Published 21 October 2015
Open published response
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
Page 2 · response
Published 21 October 2015
Open published response
18 Dec2014
Cardiff & the Vale of Glamorgan
Concerns raised4
1. Failure of systems to ensure capture and transmission of relevant donor information
2. Lack of SN-OD certification of transmitted donor information when required
3. Failure to transmit relevant medical microbiology information to the accepting transplant centre
1. Incomplete capture of donor lumbar test information
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Develop and implement an electronic system for specialist nurses to record and transmit donor data to transplant centres.
  Stated by NHS Blood and TransplantStated planned
2. Action
  Continue reminding specialist nurses to capture and provide key donor information accurately and fully during the interim period.
  Stated by NHS Blood and TransplantStated in progress
3. Action
  Audit organ-donor primary records to assess the accuracy and completeness of transferring information from medical case notes to donor files and EOS.
  Stated by NHS Blood and TransplantStated in progress
1. Action
  Share the case and its learning through specialist nurse, transplant surgeon and intensive care governance channels, including case-study presentations and NHSBT communications.
  Stated by NHS Blood and TransplantStated completed
Respondent positions 2
1. Position
  Specialist nurses cannot certify that all relevant information was transmitted because data come through multiple systems, timescales, methods and treating clinicians.
  Stated by NHS Blood and TransplantUnable to act
1. Position
  The microbiology results were unavailable before the transplant decision and therefore could not have affected the decision to transplant.
  Stated by NHS Blood and TransplantDisputes the concern
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.

Read the report on judiciary.uk
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 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
Page 2 · concerns
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
Page 2 · concerns
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
Page 2 · concerns
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
Page 2 · concerns
Open source report
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
Page 1 · response
Published 18 December 2014
Open published response
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
Page 2 · response
Published 18 December 2014
Open published response
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
Page 3 · response
Published 18 December 2014
Open published response
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
Page 2 · response
Published 18 December 2014
Open published response
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
Page 2 · response
Published 18 December 2014
Open published response
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
Page 2 · response
Published 18 December 2014
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to transmit donor kidney CMV status to the renal transplant team

Concerns raised3

Failure to ensure identification and electronic transmission of recent radiological evidence

Failure to identify and transfer key clinical information to receiving teams

Failure to ensure identification and transfer of key referral information

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised4

Failure of systems to ensure capture and transmission of relevant donor information

Lack of SN-OD certification of transmitted donor information when required

Failure to transmit relevant medical microbiology information to the accepting transplant centre

Incomplete capture of donor lumbar test information

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Actions described in response 4

Respondent positions 2

Actions described in response 4

Respondent positions 2