I thought that multiple tests were performed and relatives consent obtained before a transplant could take case. It is frightening to read that this cancer was not identified before the transplant surgery. Both recipients had to go through six cycles of chemotherapy. Luckily, they are both clear at the present time.

James Neuberger, NHS Blood and Transplant (NHSBT)'s associate medical director, said: "NHSBT has had discussions with medical directors at both the donor and recipient hospitals about this situation. Whilst we are pleased to hear that the patients involved in this situation have had a positive response to their treatment we are keen to put in place measures to ensure this does not happen again. We are currently finalising a number of recommendations, including improving communication among specialist nurses, organ donation, recipient transplant co-ordinators and surgeons."

Guidance to clinicians on obtaining consent from patients and warning them of risks – including from donor-donated tumours – was already being prepared before the incidents and has now been circulated. NHSBT is also compiling a register of such incidents, and further advice will be issued after the Liverpool case.

James Neuberger said "a transplant may be the only possible treatment for some people, who would die without one. In a situation where there are not nearly enough organs available for the number of transplants required, it often comes down to a balance of risk and benefit. Guidance is available that sets out the risks and benefits of when an organ should be used. Ultimately this is a decision for the clinician, the patient and their family."

What a relief for these two people. It is appreciated that a balance has to be struck between the need of the recipient and the shortage of donor organs; however, checks certainly need to be put in place to ensure that this does not happen again.



Patricia Wakeford

Solicitor - Clinical Negligence Team.