Concerns raised 6 Inconsistent coordination between specialist and non-specialist hospitals View source Inconsistent decision-making about whether patients remain in non-specialist areas or are transferred View source Lack of consistent understanding of appropriate specialist contacts and engagement timing View source Failure to clearly define patient information for specialist renal hospitals View source Lack of consistent awareness of and access to kidney transplant care guidelines and protocols View source Lack of consistent understanding of responsibility for initiating patient transfers View source See 3 more concerns
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
Collaborate to produce recommendations addressing specialist contact, information sharing, renal care access, responsibility and care-location concerns.
View source
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AI-generated summary
John Frederick Doyle · 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
John Frederick Doyle, a kidney transplant recipient, was admitted with rectal bleeding and a persistent cough and was later diagnosed with a severe cytomegalovirus infection after delays in testing, diagnosis and transfer to specialist care. He deteriorated to multiple organ failure and died on 30 December 2023. Concerns included unclear arrangements for contacting specialist centres, sharing information, accessing renal guidance, initiating transfers and coordinating care between specialist and non-specialist hospitals.
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. The report was sent to The British Transplantation Society; that does not assign responsibility.
PFD Monitor interpretation Inconsistent coordination between specialist and non-specialist hospitals
Wider context from the report “Concern 6: Coordination Between Specialist and Non-Specialist Hospitals
There may be variation in how specialist renal hospitals engage with non-specialist hospitals that rely on their expertise , impacting collaborative efforts in patient care. Currently, there is no clear guidance on how specialist and non-specialist teams should work together effectively to ensure consistent, high-quality care for these patients.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The British Transplantation Society; that does not assign responsibility.
PFD Monitor interpretation Inconsistent decision-making about whether patients remain in non-specialist areas or are transferred
Wider context from the report “Concern 5: Decision-Making for Patient Location
Considerations regarding whether patients should remain in non-specialist areas or be transferred may differ , potentially affecting consistency in care approaches.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The British Transplantation Society; that does not assign responsibility.
PFD Monitor interpretation Lack of consistent understanding of appropriate specialist contacts and engagement timing
Wider context from the report “Concern 1: Contacting Specialist Centres
Non-specialist medical staff may have varied understanding of the appropriate contacts and timing for engaging with specialist renal hospitals .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The British Transplantation Society; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly define patient information for specialist renal hospitals
Wider context from the report “Concern 2: Information Sharing with Specialist Centres
The specific patient information that non-specialist staff should provide to specialist renal hospitals may not always be clearly defined .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The British Transplantation Society; that does not assign responsibility.
PFD Monitor interpretation Lack of consistent awareness of and access to kidney transplant care guidelines and protocols
Wider context from the report “Concern 3: Accessibility to Renal Care Guidelines
Non-specialist staff may experience varying levels of awareness or accessibility to guidelines and protocols for treating kidney transplant patients . This could lead to a misunderstanding of the significance and urgency of the actions recommended by specialist renal hospitals.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The British Transplantation Society; that does not assign responsibility.
PFD Monitor interpretation Lack of consistent understanding of responsibility for initiating patient transfers
Wider context from the report “Concern 4: Transfer Responsibility
There may be some inconsistency across non-specialist hospitals and renal hospitals in understanding who is responsible for initiating patient transfers .
” 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 Collaborate to produce recommendations addressing specialist contact, information sharing, renal care access, responsibility and care-location concerns.
Verbatim wording from the response “Following your email request received on 12th November 2024, the UK Kidney Association (UKKA; formerly the Renal Association) and the British Transplantation Society (BTS) have collaborated and produced the following recommendations in response to your concerns.” Source location Response from UKKA and BTS
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 Specialist-led care is considered sufficient, so clinicians should not necessarily need to refer to renal care guidelines.
Verbatim wording from the response “• As access to Guidelines could lead to a misunderstanding of the significance and urgency of required actions; the critical action in this case would be to contact the Specialist Centre.” Source location Response from UKKA and BTS
Open published response
19 Jun 2019 Tien Dong PHUNG · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2 Risk of Strongyloides hyperinfection syndrome progressing to respiratory distress and multi-organ failure View source Lack of routine screening for Strongyloides stercoralis forms before transplant surgery View source
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Tien Dong PHUNG · 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
Tien Dong PHUNG died in hospital on 25 December 2018 after deteriorating following a kidney transplant and developing infection, fluid overload and a cardiac arrest. Post-mortem examination identified Strongyloides stercoralis in his lungs, and the medical cause of death was recorded as pulmonary strongyloidiasis. The concerns included that Strongyloides is not routinely screened for before transplant surgery and can present with non-specific symptoms, particularly in people whose immune systems are compromised.
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. The report was sent to The British Transplantation Society; that does not assign responsibility.
PFD Monitor interpretation Risk of Strongyloides hyperinfection syndrome progressing to respiratory distress and multi-organ failure
Wider context from the report “(1) Strongyloides stercoralis forms are not routinely screened for prior to transplant surgery. If identified early, they are treatable
(2) Strongyloides hyperinfection syndrome presents with non-specific symptoms such as abdominal pain, vomiting, intestinal obstruction, cough, wheezing and chest pain. It can evolve into respiratory distress and multi-organ failure.
(3) Strongyloidiasis is estimated to affect up to 300 million people worldwide. The infection is particularly prevalent in tropical and subtropical regions including a number of common travel destinations such as Thailand and Brazil. Mr Phung was born in Vietnam but had lived in the UK for many years.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The British Transplantation Society; that does not assign responsibility.
PFD Monitor interpretation Lack of routine screening for Strongyloides stercoralis forms before transplant surgery
Wider context from the report “(1) Strongyloides stercoralis forms are not routinely screened for prior to transplant surgery. If identified early, they are treatable
(2) Strongyloides hyperinfection syndrome presents with non-specific symptoms such as abdominal pain, vomiting, intestinal obstruction, cough, wheezing and chest pain. It can evolve into respiratory distress and multi-organ failure.
(3) Strongyloidiasis is estimated to affect up to 300 million people worldwide. The infection is particularly prevalent in tropical and subtropical regions including a number of common travel destinations such as Thailand and Brazil. Mr Phung was born in Vietnam but had lived in the UK for many years.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations