Patient died after surgeon spilled stomach contents onto donor’s organs

Patient died after surgeon spilled stomach contents onto donor’s organs

A 25-year-old patient has received a damages pay-out over the mistake that wasn’t recorded (Picture: Getty/PA) A surgeon spilled the infected cont

Popular blood pressure drug recalled in the U.S. for cancer-causing impurity
Giant heroin spoon sculpture appears outside offices of Rhode Island-based pharmaceutical company
Over 3,000 patients possibly exposed to HIV, hepatitis at New Jersey hospital
Surgeon didn't report mistake
A 25-year-old patient has received a damages pay-out over the mistake that wasn’t recorded (Picture: Getty/PA)

A surgeon spilled the infected contents of a donor’s stomach and transplanted the bacteria-riddled organs into other NHS patients, causing one of them to die.

The surgeon from Oxford University Hospital NHS Foundation Trust, failed to tell officials what he had done and the incident was not recorded.

After accidentally cutting the donor’s stomach, several organs became infected with Candida albicans – a type of fungal infection – and were transplanted into three patients.

The incident, which happened in Wales in August, 2015, saw a 36-year-old recipient die of an aneurysm caused directly by infection from the donated liver.

A second patient, a 25-year-old parent with children, became life-threateningly ill and needed their transplanted kidney removed after suffering extensive internal bleeding.

A third patient, aged 44, who received a combined kidney and pancreas transplant, fell ill but later recovered.



The incident only came to light after surgeons at Cardiff & Vale University Health Board raised the alarm with the Human Tissue Authority and the Welsh Government.

A sign for the Oxford University Hospital NHS Foundation Trust
The incident happened at Oxford University Hospital NHS Foundation Trust (Picture: PA)

They became worried when the parent – who was under their care at the University Hospital of Wales – became seriously unwell following their organ transplant.

The patient, who does not wish to be named but is from South Wales, had to have the kidney removed as an emergency after suffering extreme pain.

They were put in an induced coma and needed 16 blood transfusions. They also ended up on dialysis for more than a year, despite not having needed it previously.

A serious incident report by NHS Blood and Transplant said the surgeon from Oxford ‘had no recollection of anything of note during the retrieval’.

However, ‘upon reflection’, he admitted a ‘small nick’ had been caused to the donor’s stomach during the procedure, and a ‘small volume of stomach content was spilt’.

The 25-year-old took legal action against Oxford University Hospital NHS Foundation Trust – where the surgeon is still employed – and the NHS has agreed damages of more than £215,000.

The trust admitted it had been in breach of duty of care by the failure of the surgeon to record the cut into the donor’s stomach, meaning the patient’s doctors were unaware of the risk of infection.

Three patients became ill after the infected organs were transplanted (Picture: Getty)

The trust’s lawyers claimed that, despite the stomach spill, even if it had been recorded at the time of transplant, the risk would have been considered low.



But Jodi Newton, representing the patient, said the surgeon had been ‘reckless’ and the act was ‘extremely damaging for patient trust in surgeons’.

She added: ‘It denied all involved, from the patients to the surgeons transplanting the organs, the knowledge of the full facts. It cannot be excused at any level.’

The patient has been left with life-limiting problems, including nerve damage linked to the removal of the infected kidney, along with pains in their legs and feet and have high blood pressure.

They said it has had a huge impact on their children’s lives, adding: ‘What angers me to this day is that fact that the surgeon who removed the organs from the donor wasn’t honest.

‘It was only when people who received the organs became unwell that the truth was told.

‘I think that is completely unacceptable, and it makes you wonder how many other potentially life-threatening mistakes are being made and not owned up to or covered up’.

Professor Meghana Pandit, chief medical officer at Oxford University Hospitals NHS Foundation Trust, apologised to the patient, adding: ‘This is a very unusual circumstance and we are keen to ensure that we do everything we can to make sure it doesn’t happen again in future.’

John Forsythe, medical director for organ donation and transplantation at NHSBT, said: ‘Our thoughts are with the recipients and their families over this sad and unusual case.


‘We acted quickly to investigate what happened and we worked with transplant centres afterwards. Our report concluded the infection of the transplanted organ may have arisen during the retrieval procedure.

‘Candida is resident in everyone’s digestive system and it is usually harmless.

‘If a surgeon is retrieving abdominal organs, particularly the pancreas, there is the possibility of it being spread to the organs that will be transplanted. If that happens, there is usually no harm to the patient. Sadly, this is not always the case.’

It is unclear whether the family of the 36-year-old who died or the 44-year-old are aware of the incident.