Avoidable errors to blame for wrong organ removals

Faulty data conversion software led to mistakes in the way information was transferred from one government agency to another.

The government-ordered review, by Sir Gordon Duff, said UK Transplant used faulty software to upload data on donation wishes from the Driver and Vehicle Licensing Agency (DVLA) when it moved to a new computer system in 1999.

The DVLA application form includes a section where people can register their wish to become an organ donor.

The mistake came to light in February this year when NHS Blood and Transplant wrote letters to new donors thanking them for joining the register, and outlining what organs they had agreed to donate.

Respondents wrote back complaining that the information was wrong.

After detecting the error, NHS Blood and Transplant, which runs the organ donation register, was able to correct 400,000 of the flawed records. However, some 800,000 in total contained errors.

In the cases where organs were removed, families were asked for permission, but their decisions were based on misinformation about the wishes of their relatives.

Donors can give permission for any of their organs to be taken, or can specify which organs they wish to give.

Many have strong views about what should be removed, with consent frequently withheld for eyes to be donated, or bodies to be used in medical research.

Today’s review praised NHS Blood and Transplant for its “sensitive handling” of the incident but said errors could have been avoided if more robust procedures had been in place in 1999 when the mistake was made.

Sir Gordon said there was a growing need for the organ donor register to become more interactive and to be made more secure. There are currently more than 17 million people on the register.

Other recommendations include standardising the form used to give consent, the continuation of writing letters to people to thank them for their offer of donating organs, and for an external firm to be brought in to review security.

Sir Gordon said: “Organ transplantation is a much needed life-saving procedure.

“People who generously agree to donate their organs should be reassured that the error has been dealt with effectively and that steps have been taken to minimise the risk of it happening again.

“The current organ donor register, though still capable of being an effective tool, has some inherent constraints.

“I have therefore recommended that as soon as resources allow, NHS Blood and Transplant should design and commission a new register which will be better equipped to deal with the operational demands now placed on it.”

Public health minister Anne Milton said: “Organ transplants save lives. However, the system relies on the generosity of people willing to donate.

“I would like to thank Sir Gordon for his work on producing this clear report.

“It is reassuring to hear that NHS Blood and Transplant handled the situation well once problems were identified.

“Organ transplants are vital and I know that NHS Blood and Transplant will make sure such a situation never arises again.”