First report 24 Oct 2013•Latest report 27 Feb 2026
Recipient record
Reports, concerns and published responses
Health and care · Special health authority. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.
Reports
4
Naming this recipient
Published responses
100%
Found for named reports
Concerns addressed
10
Across all linked responses
Stated actions
24
Described in responses
Reports over time
Reports over time
Reports naming this recipient by issue year.
Evidence profile
Report topics
Share of this recipient’s reports compared with all other recipients.
100%published responses found
24stated actions described
Topic comparisons are not available in the current evidence snapshot.
Concerns and recipient responses
Statements from NHS Blood and Transplant linked to the concerns in each report. Select any concern, action or position to view the source wording.
Manchester South
Concerns raised2
Delayed availability of suitable donor livers for children in the “super urgent” category
National shortage of suitable donor livers for children in the “super urgent” category
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised.6
Action
Continue collaborating with coroners, police, forensic pathologists and medical examiners to maximise potential organ donation.
Stated in progressThe respondent said that this action was in progress when they made their response on 9 March 2026.
Action
Review clinical protocols and practices to widen the pool of potential organ donors.
Stated in progressThe respondent said that this action was in progress when they made their response on 9 March 2026.
Action
Increase use of novel technologies for donation after circulatory death.
Status unclearThe respondent did not make the status of this action clear when they made their response on 9 March 2026.
Action
Improve access to and consistency of neurological-death testing to increase the number of potential donors after brain death.
Stated in progressThe respondent said that this action was in progress when they made their response on 9 March 2026.
Action
Review the family-approach process to enhance organ-donation consent rates.
Stated in progressThe respondent said that this action was in progress when they made their response on 9 March 2026.
Action
Introduce Assessment and Recovery Centres using specialised machine perfusion to assess, repair and recondition marginal organs for transplantation.
Status unclearThe respondent did not make the status of this action clear when they made their response on 9 March 2026.
Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.1
Position
National guidance recommends splitting only DBD livers because DCD splitting carries increased graft-failure risk and remains experimental.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Inner North London
Concerns raised2
Risk of Strongyloides hyperinfection syndrome progressing to respiratory distress and multi-organ failure
Lack of routine screening for Strongyloides stercoralis forms before transplant surgery
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised.3
Action
Include information about Strongyloides infection as shared learning in NHSBT's Medical Bulletin and Cautionary Tales.
Stated plannedThe respondent said that this action was planned when they made their response on 23 August 2019.
Action
Discuss potential future guidance on Strongyloides infection in transplantation with the BTS standards committee.
Stated plannedThe respondent said that this action was planned when they made their response on 23 August 2019.
Action
Write to SaBTO about the case and request a clear position on donor screening.
Stated plannedThe respondent said that this action was planned when they made their response on 23 August 2019.
Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.2
Position
Local transplant hospitals and organisations are responsible for setting recipient screening policies under local protocols.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
SaBTO is responsible for advising Ministers and health services on donor-transmitted disease risk management, including donor screening.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Cardiff & the Vale of Glamorgan
Concerns raised9
Failure to record first lumbar puncture test results in the core donor data form
Failure of systems to ensure capture and transmission of relevant donor information
Failure of accepting consultants or centres to view the EOS system before organ acceptance decisions
Lack of SN-OD certification of transmitted donor information when required
Failure to transmit relevant medical microbiology information to the accepting transplant centre
Absence of team-based decision-making about prophylactic anti-viral therapy
Use of an inadequate standard consent form for transplant operations
Incomplete capture of donor lumbar test information
Absence of team-based transplant acceptance decision-making
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised.4
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 in progressThe respondent said that this action was in progress when they made their response on 18 December 2014.
Action
Continue reminding specialist nurses to capture and provide key donor information accurately and fully during the interim period.
Stated in progressThe respondent said that this action was in progress when they made their response on 18 December 2014.
Action
Develop and implement an electronic system for specialist nurses to record and transmit donor data to transplant centres.
Stated plannedThe respondent said that this action was planned when they made their response on 18 December 2014.
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 completedThe respondent said that this action was complete when they made their response on 18 December 2014.
Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.2
Position
Specialist nurses cannot certify that all relevant information was transmitted because data come through multiple systems, timescales, methods and treating clinicians.
Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
The microbiology results were unavailable before the transplant decision and therefore could not have affected the decision to transplant.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Surrey
Concerns raised1
Potential contraindication of platelet transfusion following stem cell transplant
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised.1
Action
Undertake an international randomised study with NHS hospitals and other organisations investigating the benefits and risks of prophylactic platelet transfusion.
Stated completedThe respondent said that this action was complete when they made their response on 18 December 2013.
Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.1
Position
Current evidence and guidelines support platelet transfusion after chemotherapy and stem cell transplantation because bleeding risks outweigh transfusion risks.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations