David Smith
14 Aug 2019 · Coroner Zak Golombeck · Manchester (City)
The coroner's concerns
1. lack of informed consent
“The consent process - | found that the CMV status of the donor's kidneys (listed as positive on the Electronic Offering System form) was never communicated to the Deceased for him to consider the risks of proceeding with the transplantation, and for him to provide informed consent”
2. missing CMV status information
“Recording of the CMV status - When the plan for the deceased's surgery was communicated to the Renal transplant team in an email, this did not include reference to the donor's CMV status, nor did it attach the relevant EOS form. Consideration should be given to introducing a process in which the EOS form itself is sent onwards to the Renal transplant team to ensure important information such as the CMV status is not missed by the treating clinicians.”
Responses
2019-0271-Response-by-Manchester-University-NHS-Trust.pdf ↗· Manchester University NHS Foundation Trust
Stated action
“The consent process for transplantation has been strengthened all along the listing pathway, and all recipients are specifically informed during the assessment about CMV infection and its effects, morbidity and mortality. If they are being offered transplantation with a CMV positive kidney when they are CMV negative, they are considered high risk for developing CMV infection. This is discussed prior to transplantation with the recipient during the consent process and specifically documented.”