One patient died and two became seriously ill after they were given infected organs due to an unreported surgical mishap.
A surgeon from Oxford was removing organs for transplant when they accidentally cut the donor’s stomach , spilling some of the contents, in August 2015.
But officials were not told and the incident, which happened in Wales, was not recorded.
Several of the organs became contaminated with a fungal infection – candida albicans – before being transplanted into unsuspecting
One recipient, 36, died of an aneurysm caused by infection from the donated liver.
A second patient, 25, became so ill that their transplanted kidney had to be removed and a third, 44, fell ill after their kidney and pancreas transplant but recovered.
Concerns were raised by those who treated the second patient at a hospital in Wales.
That patient suffered extreme pain and internal bleeding as a result of the infected organ. They were in an induced coma, needed 16 blood transfusions and also dialysis for more than a year.
After taking legal action against Oxford University Hospital NHS Foundation Trust, where the surgeon still works, the patient accepted damages of more than £ 215, 000.
The trust admitted it had breached a duty of care by the surgeon’s failure to record the cut into the donor’s stomach.
The trust’s lawyers said that, even if the spill had been known about at the time of the transplant, the risk would still have been low.
But solicitor Jodi Newton, a medical negligence specialist at Hudgell Solicitors, representing the patient, said: “No matter what the outcome had been in this case, the failure to ensure that everybody involved was aware of the serious accident which occurred when removing the organs from the donor was reckless on the part of the surgeon.
“It denied all involved, from the patients to the surgeons transplanting the organs, the knowledge of the full facts. “
The patient, who still suffers the physical effects of the failed transplant, said:” 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.
Professor Meghana Pandit, chief medical officer at Oxford University Hospitals NHS Foundation Trust, said: “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 cas e.
“We acted quickly to investigate what happened and we worked with transplant centers 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. “