Robert Stuart and Darren Hughes
18 Dec 2014 · Coroner Christopher Woolley · Cardiff & the Vale of Glamorgan
The coroner's concerns
1. incomplete donor data form
“The core donor data form could have contained more information as to the second lumbar test performed on the donor and could have given the results of the first lumbar puncture test”
2. untransmitted microbiology report
“There was information available on the medical microbiology report which was not passed on to the accepting transplant centre”
3. telephone acceptance without EOS system
“The Kidneys were accepted by the transplant centre following a telephone conversation between the consultant and the transplant coordinator”
4. solo acceptance decision
“The kidneys were accepted by the consultant acting alone”
5. unsuitable standard consent form
“The Coroner heard that a standard consent form is used for all operations, and heard evidence that this has proved unsatisfactory for transplant operations where issues have to be covered that are not catered for by the standard form”