Shared learning

Cautionary tales

Cautionary Tales aims to provide insight into some of the clinical incidents reported to ODT. The aim is to share learning from incidents and so improve outcomes for patients.

Cautionary Tales, issues 1-34 (2013-2024)

DCD heart debriefs – learning and actions

A 12-month pilot of the UK wide DCD heart retrieval service was recently launched on the 7th September 2020. As part of that pilot it was agreed in the initial stages that the ODT Clinical Governance Team would facilitate debriefs for any donors where DCD heart retrieval proceeded.

The purpose of the debriefs are to include, wherever possible, the people that were involved in the donor process (SNODs, Hub Ops, Transplant Centres, NORS and IMT) to allow an opportunity to look at what went well and anything we can do to strengthen the process.

The attachments summarise the key learning and findings and the actions taken since the debriefs.

Additional shared learning

There are times when it is felt beneficial to share more detailed learning around specific cases due to the potential benefits to patient outcomes. On these occasions any relevant findings, learning or reports can be found in this section.

Guidance for surgical count during solid organ donor retrieval (PDF 110KB)

Recipients' deaths following kidney transplant: publication of investigation reports

In December 2013, two patients died after receiving kidney transplants from the same donor. It was a tragic and rare case. At the time of death, the donor was showing signs of encephalitis of an unknown cause. The donor was characterised and the organs were offered.

After death, the cause of the donor's encephalitis was identified as Halicephalobus gingivalis, an extremely rare infection that has only been reported in humans five times previously in the medical literature.

Sadly, the recipients of the donor's organs both died a few weeks after their transplants.

NHS Blood and Transplant and the other organisations involved thoroughly investigated what happened.

We are publishing our internal NHS Blood and Transplant investigation into the incident together with an external Review we commissioned, to ensure that colleagues working in organ donation and transplantation across the UK can also take learning from this sad case.

NHS Blood and Transplant has carefully considered our own investigation report, the investigation carried out on behalf of the hospital where the transplants were carried out and the external review we commissioned, which was completed by Professor O'Donoghue and Dr Gunning. Following the recommendations within all these reports action plans were agreed.

Shared learning

Cautionary tales

DCD heart debriefs – learning and actions

Additional shared learning

In this section

Register to be an organ donor