Recipient

The British Transplantation Society

First report 19 Jun 2019•Latest report 12 Nov 2024

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Registered charity. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 2
Published responses: 100%
Concerns addressed: 8
Stated actions: 8

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

8stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from The British Transplantation Society linked to the concerns in each report. Select any concern, action or position to view the source wording.

12 Nov2024
Coventry and Warwickshire
Concerns raised6
1. Inconsistent coordination between specialist and non-specialist hospitals
2. Inconsistent decision-making about whether patients remain in non-specialist areas or are transferred
3. Lack of consistent understanding of appropriate specialist contacts and engagement timing
1. Failure to clearly define patient information for specialist renal hospitals
2. Lack of consistent awareness of and access to kidney transplant care guidelines and protocols
3. Lack of consistent understanding of responsibility for initiating patient transfers
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Collaborate to produce recommendations addressing specialist contact, information sharing, renal care access, responsibility and care-location concerns.
  Stated completed
Respondent positions 1
1. Position
  Specialist-led care is considered sufficient, so clinicians should not necessarily need to refer to renal care guidelines.
  Existing arrangements considered sufficient
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
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
Page 1 · response
Published 12 November 2024
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-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
Page 1 · response
Published 12 November 2024
Open published response
19 Jun2019
Inner North London
Concerns raised2
1. Risk of Strongyloides hyperinfection syndrome progressing to respiratory distress and multi-organ failure
2. 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.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
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

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised6

Inconsistent coordination between specialist and non-specialist hospitals

Inconsistent decision-making about whether patients remain in non-specialist areas or are transferred

Lack of consistent understanding of appropriate specialist contacts and engagement timing

Failure to clearly define patient information for specialist renal hospitals

Lack of consistent awareness of and access to kidney transplant care guidelines and protocols

Lack of consistent understanding of responsibility for initiating patient transfers

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

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.1

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

Actions described in response 1

Respondent positions 1