PFD report

Maisie Kate Almond · Prevention of Future Deaths report

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Issued 27 Feb 2026•Manchester South

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
2

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
15

Described in responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Report evidence summary

Concerns raised2

  1. Delayed availability of suitable donor livers for children in the “super urgent” category
  2. 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 a recipient says it has done, is doing, or plans to do in response to a concern raised.9

  1. Action

    Develop the Assessment and Recovery Centre programme as a national multi-organ approach, with phased lung, liver and kidney pilots during 2026.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 9 March 2026.
  2. Action

    Establish the Organ Donation Joint Working Group and publish its ten actions for improving deceased organ donation.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 9 March 2026.
  3. Action

    Provide funding for the development and mobilisation of Assessment and Recovery Centre pilot schemes.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 9 March 2026.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    Clinicians, rather than the Department, decide whether organs including DCD livers are clinically suitable for transplantation.

    Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Delayed availability of suitable donor livers for children in the “super urgent” category

Wider context from the report

“During the inquest, I heard evidence from a consultant paediatric hepatologist that there is a national shortage of donor livers generally and particularly for children in the “super urgent” category. The clinical guidance not to utilise cardiac death donor livers in such cases due to the poor historical outcomes has narrowed the pool of suitable donor livers to those arising from brain deaths. Altruistic living liver donations are generally not available for super urgent cases. The evidence I received was that the number of donor livers has reduced by a third and the effect is that whereas, historically, a donor liver could be expected to be made available within 48 hours, the wait has now extended to up to a week. That delay gives rise to a clear risk that lives will be lost due to the unavailability of suitable donor organs. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

National shortage of suitable donor livers for children in the “super urgent” category

Wider context from the report

“During the inquest, I heard evidence from a consultant paediatric hepatologist that there is a national shortage of donor livers generally and particularly for children in the “super urgent” category. The clinical guidance not to utilise cardiac death donor livers in such cases due to the poor historical outcomes has narrowed the pool of suitable donor livers to those arising from brain deaths. Altruistic living liver donations are generally not available for super urgent cases. The evidence I received was that the number of donor livers has reduced by a third and the effect is that whereas, historically, a donor liver could be expected to be made available within 48 hours, the wait has now extended to up to a week. That delay gives rise to a clear risk that lives will be lost due to the unavailability of suitable donor organs. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 the Assessment and Recovery Centre programme as a national multi-organ approach, with phased lung, liver and kidney pilots during 2026.

Verbatim wording from the response

“with the aim of improving organ utilisation, reducing unwarranted variation and supporting more transplants to occur.”

Source location

Response from Department of Health & Social Care
Page 4 · response
Published 9 March 2026

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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

Establish the Organ Donation Joint Working Group and publish its ten actions for improving deceased organ donation.

Verbatim wording from the response

“Organ Donation Joint Working Group (ODJWG)”

Source location

Response from Department of Health & Social Care
Page 2 · response
Published 9 March 2026

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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

Provide funding for the development and mobilisation of Assessment and Recovery Centre pilot schemes.

Verbatim wording from the response

“Assessment and Recovery Centres”

Source location

Response from Department of Health & Social Care
Page 3 · response
Published 9 March 2026

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 collaborating with coroners, police, forensic pathologists and medical examiners to maximise potential organ donation.

Verbatim wording from the response

“• Coroners working group: continue to collaborate with HM Coroners, Police, Forensic Pathologists and Medical Examiners to ensure we can maximise the number of potential organ donors, where possible. This PFD is scheduled for discussion at the next meeting.”

Source location

Response from NHS Blood and Transplant Service
Page 3 · response
Published 9 March 2026

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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

Review clinical protocols and practices to widen the pool of potential organ donors.

Verbatim wording from the response

“Action being taken NHSBT is working to ensure that we address the challenges in the donation pathway. Some of the various initiatives underway include but are not limited to:”

Source location

Response from NHS Blood and Transplant Service
Page 2 · response
Published 9 March 2026

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

Increase use of novel technologies for donation after circulatory death.

Verbatim wording from the response

“• Increased use of novel technologies for DCD donation.”

Source location

Response from NHS Blood and Transplant Service
Page 3 · response
Published 9 March 2026

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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

Improve access to and consistency of neurological-death testing to increase the number of potential donors after brain death.

Verbatim wording from the response

“• Clinical Practice: Enhancements in clinical protocol and practice to widen the pool of potential donors being reviewed. Alongside this, work to look at neurological death testing improving access and consistency of testing has commenced. This work will endeavour to increase the number of DBD donors in the UK, with the ultimate of ensuring more organs can be available for liver splitting and cardiothoracic transplantation. Streamlining the family approach to enhance consent rates being reviewed.”

Source location

Response from NHS Blood and Transplant Service
Page 2 · response
Published 9 March 2026

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

Review the family-approach process to enhance organ-donation consent rates.

Verbatim wording from the response

“• Clinical Practice: Enhancements in clinical protocol and practice to widen the pool of potential donors being reviewed. Alongside this, work to look at neurological death testing improving access and consistency of testing has commenced. This work will endeavour to increase the number of DBD donors in the UK, with the ultimate of ensuring more organs can be available for liver splitting and cardiothoracic transplantation. Streamlining the family approach to enhance consent rates being reviewed.”

Source location

Response from NHS Blood and Transplant Service
Page 2 · response
Published 9 March 2026

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

Introduce Assessment and Recovery Centres using specialised machine perfusion to assess, repair and recondition marginal organs for transplantation.

Verbatim wording from the response

“• Introduction of Assessment and Recovery Centres (ARCs) for organ donation. ARCs improve organ donation by utilising specialized machine perfusion to assess, repair, and recondition "marginal" organs previously deemed unsuitable for transplant. These centres aim to increase the number of viable organs, reduce transplant waiting lists, and allow for safer, high-quality organ transplantation.”

Source location

Response from NHS Blood and Transplant Service
Page 3 · response
Published 9 March 2026

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

Clinicians, rather than the Department, decide whether organs including DCD livers are clinically suitable for transplantation.

Verbatim wording from the response

“The Department recognises the concerns raised in your report about the impact that limitations on suitable donor liver availability can have on children requiring super urgent transplantation. Decisions regarding the clinical suitability of organs for transplantation, including the use of DCD livers, are made by clinicians and are based on the best available evidence. NHSBT has advised that, while DCD livers are an important source of organs when transplanted as whole livers, they are not routinely split, which is often required for paediatric cases. This is because splitting DCD livers is associated with a higher risk of graft failure and poorer outcomes for recipients.”

Source location

Response from Department of Health & Social Care
Page 4 · response
Published 9 March 2026

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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

Current evidence-based guidance limiting routine splitting of DCD livers is kept under regular review and will change only when robust evidence supports safe improvement.

Verbatim wording from the response

“The Department recognises the concerns raised in your report about the impact that limitations on suitable donor liver availability can have on children requiring super urgent transplantation. Decisions regarding the clinical suitability of organs for transplantation, including the use of DCD livers, are made by clinicians and are based on the best available evidence. NHSBT has advised that, while DCD livers are an important source of organs when transplanted as whole livers, they are not routinely split, which is often required for paediatric cases. This is because splitting DCD livers is associated with a higher risk of graft failure and poorer outcomes for recipients.”

Source location

Response from Department of Health & Social Care
Page 4 · response
Published 9 March 2026

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

National guidance recommends splitting only DBD livers because DCD splitting carries increased graft-failure risk and remains experimental.

Verbatim wording from the response

“As a result of this shift, fewer livers now meet the criteria for splitting, as DCD livers are not routinely split due to the increased risk of graft failure. While all donor types carry some degree of risk, splitting a DCD liver presents particular challenges. Nevertheless, DCD donors remain an important source of organs across the UK. Advances in emerging technologies may in time support the safe splitting of DCD livers, but at present, national guidance continues to recommend splitting only DBD livers.”

Source location

Response from NHS Blood and Transplant Service
Page 2 · response
Published 9 March 2026

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.6

  1. 1

    Continue investing in research into preventing and treating liver failure, including approaches that stabilise patients while they await transplantation.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 9 March 2026.
  2. 2

    Establish Clinical Leads for Organ Utilisation in every transplant centre to drive local improvement and shared learning.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 9 March 2026.
  3. 3

    Maintain momentum to continue improving organ utilisation and achieve better outcomes for patients and families across the UK.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 9 March 2026.
  4. 4

    Establish the Implementation Steering Group for Organ Utilisation to deliver recommendations and improve collaboration, pathways, clinical leadership and organ allocation.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 9 March 2026.
  5. 5

    Share the Prevention of Future Deaths report with the wider donation community to reinforce consideration of organ donation in appropriate clinical circumstances.

    Stated by NHS Blood and TransplantStated completedThe respondent said that this action was complete when they made their response on 9 March 2026.
  6. 6

    Continue marketing, communications and societal-action strategies to raise awareness and public support for organ donation.

    Stated by NHS Blood and TransplantStated in progressThe respondent said that this action was in progress when they made their response on 9 March 2026.

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 investing in research into preventing and treating liver failure, including approaches that stabilise patients while they await transplantation.

Verbatim wording from the response

“Research into the Prevention and Treatment of Liver Failure”

Source location

Response from Department of Health & Social Care
Page 4 · response
Published 9 March 2026

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

Establish Clinical Leads for Organ Utilisation in every transplant centre to drive local improvement and shared learning.

Verbatim wording from the response

“• The ISOU has supported wider system improvements, including strengthening clinical leadership, standardising pathways, promoting collaboration between transplant centres, and enabling innovation in how organs are assessed and allocated. Clinical Leads for Organ Utilisation have been established in all transplant centres to drive local improvement and shared learning.”

Source location

Response from Department of Health & Social Care
Page 3 · response
Published 9 March 2026

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

Maintain momentum to continue improving organ utilisation and achieve better outcomes for patients and families across the UK.

Verbatim wording from the response

“• As the ISOU concludes the Department is committed to maintaining momentum to continue to improve organ utilisation and achieving better outcomes for patients and families across the UK.”

Source location

Response from Department of Health & Social Care
Page 3 · response
Published 9 March 2026

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

Establish the Implementation Steering Group for Organ Utilisation to deliver recommendations and improve collaboration, pathways, clinical leadership and organ allocation.

Verbatim wording from the response

“Implementation Steering Group for Organ Utilisation”

Source location

Response from Department of Health & Social Care
Page 3 · response
Published 9 March 2026

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 Prevention of Future Deaths report with the wider donation community to reinforce consideration of organ donation in appropriate clinical circumstances.

Verbatim wording from the response

“We have shared the PFD with the wider donation community to reinforce the importance of considering organ donation in all appropriate clinical circumstances.”

Source location

Response from NHS Blood and Transplant Service
Page 3 · response
Published 9 March 2026

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 marketing, communications and societal-action strategies to raise awareness and public support for organ donation.

Verbatim wording from the response

“Action being taken NHSBT is working to ensure that we address the challenges in the donation pathway. Some of the various initiatives underway include but are not limited to:”

Source location

Response from NHS Blood and Transplant Service
Page 2 · response
Published 9 March 2026

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Official responses located
2/2

Data last updated 7 September 2026