David John Smith · Prevention of Future Deaths report

I concluded the inquest into the death of David John Smith on 12th February 2019 and recorded that he died from.

1a Multiple Organ Failure
1b CMV pneumonitis with pneumonia and acute respiratory distress syndrome
1c Renal transplant of a CMV positive kidney for fibrillary glomerulonephritis

The deceased underwent a dual cadaveric renal transplant on 11 November 2016 following diagnosis of fibrillary glomerulonephritis The CMV status of the donor kidneys was listed as positive on the Electronic Offering System (EOS) form, however this information was never communicated to the deceased for him to consider the risks of proceeding with the transplantation.

The plan for the deceased’s surgery was communicated to the Renal transplant team in an email on the morning of 11 November 2016. This email did not, as it should have done, include reference to the donor’s CMV status, nor did it attach, as it should have done the relevant EOS form

The deceased proceeded to surgery, whereby he was operated on by the consultant surgeon and a clinical fellow. Both clinicians had the opportunity to consider the EOS form upon their respective authoring and checking of the operation note. The clinical fellow authored the operation note and erroneously entered the donor’s CMV status as negative. The consultant did not review the operation note as he should have done and did not cross-check the donor’s CMV status so to action post-operative care.

Had the donor’s CMV status been recorded correctly on the operation note, the deceased (who had a negative CMV status himself) should have received oral Valganciclovir by 13 November 2016 at the latest This was due to the deceased being a high risk as per the hospital trust’s CMV policy.

When the deceased was transferred to the ward, a flowsheet (as per the hospital trust’s policy) was commenced. On the flowsheet both the donor’s and the deceased’s CMV statuses were recorded as negative, and together with the plan recorded on the operation note, no prophylaxis for CMV was commenced. The deceased was diagnosed with the CMV virus on 16 December 2016 and was admitted to the renal transplant unit and commenced treatment for CMV.

The deceased was diagnosed with Ganciclovir resistance in March 2017 and in June 2017 the deceased commenced intravenous Foscarnet. The deceased continued to deteriorate and died at the Manchester Royal Infirmary on 5 July 2017.

There were numerous missed opportunities for the donor’s CMV status to have been correctly recorded, and these missed opportunities were made more likely as a result of a system that was in place without the necessary checks and balances. One simple but fundamental error of a mis-recording led to the deceased not receiving the necessary medication, and this contributed to his death.

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.