When a loved one is admitted to hospital for life-saving treatment, you expect them to receive the best possible quality of care. Unfortunately, that isn’t always the case. In the event of medical negligence occurring, our specialist medical negligence lawyers are on hand to help.

In their 2018/2019 Annual report, NHS revealed that they received 10,678 new clinical negligence claims. Amounting to almost 30 claims per day, medical negligence may be more common than you originally thought and, sadly, the effects of clinical negligence can sometimes be fatal. At TEN Legal, we recently represented a client whose husband sadly died as a result of clinical negligence.

Fatal kidney transplant due to medical negligence

David John Smith, a father-of-two from Stockport, fell victim to medical negligence after a Surgeon made a fatal error when completing paperwork following Mr Smith’s double kidney transplant. This simple yet fundamental error meant Mr Smith didn’t receive the correct assistance which in turn contributed to his death.

We represented Mr Smith’s wife, Kerry Smith, as she filed for Medical Negligence on her husband’s behalf.

When receiving his kidney transplant as a treatment for kidney failure in November 2016, Mr Smith was given kidneys infected with Cytomegalovirus (CMV). Similar to the herpes virus, CMV is a common virus that, once contracted, remains in the person’s body for life. When spread from one individual to another via organ donation, CMV poses a particular risk to the organ recipient as their immune system is already compromised.

The risk of CMV in kidney transplants

Approximately one-quarter of donor recipients are given kidneys containing CMV when receiving a kidney transplant. Because of its high prevalence and harmful effects for transplant recipients, it is mandatory for all organ donors and recipients to be screened for CMV prior to, or at the time of, transplantation. If an organ recipient who tests negative for CMV, like our client’s husband John Davies Smith, receives a CMV-positive organ, it is the Doctor’s duty of care to ensure they are made aware of this prior to surgery and that they are given the appropriate ongoing treatment following the transplant surgery.

The fatal effect of medical negligence in this case

In this instance, David John Smith, was given kidneys infected with CMV. However, due to the surgeon making a ‘transcription error’, there was no record of this in his aftercare notes. If there had been a record of the kidneys testing positively for CMV, our 52-year-old client would have been prescribed a long-term course of prophylaxis – treatment for the virus to prevent the spread of disease or infection.

Instead, Mr Smith died of multiple organ failure at Manchester Royal Infirmary (MRI), part of Manchester University NHS Foundation Trust, just months after receiving what was supposed to be a life-saving treatment. A post-mortem examination conducted by coroner Zak Golombeck revealed CMV pneumonitis and renal transplant for fibrillary glomerulonephritis (kidney disease) were contributing factors to Mr Smith’s death.

Around a month after his kidney donation, Mr Smith started to suffer from stomach pains. Despite blood tests carried out on December 2 showing that he tested positive for CMV, there was no record made in the clinician’s notes.

It was only when there was a ‘high level’ of the virus that Mr Smith started to receive treatment. Recalling these events, Mrs Smith described this news as a ‘big shock’ to the family. Kerry also told us that when her husband had asked doctors why the CMV wasn’t on his records, Mr Smith was told a ‘mistake had been made’.

Failure to include this information in the patient’s notes resulted in delays in the treatment for the CMV – which doctors discovered had come from the transplant kidneys. Ultimately, these delays in treatment rendered the antiviral medications ineffective and our client’s husband passed on July 5, seven months after his kidney transplant.

The court hearing for this clinical negligence case

During the course of the inquest, the evidence provided revealed matters giving rise to concern. In the court hearing for this case, the court heard from surgeon Adham El Bakry, who was on duty on the morning of the transplant. Dr El Bakry confirmed that the transplant kidneys were listed as CMV-positive on the Electronic Offering System (EOS), an organ transplant data system, that was available to him before the surgery. However, the doctor wrote on the aftercare form following surgery that the kidneys were CMV-negative. When questioned on how this error had been made, Dr El Bakry stated that he believes it was due to a ‘transcription error’.

The court also heard that there was no mention of CMV on the handover email sent from the registrar of the renal transplant team to Dr El Bakry on the morning of the surgery. Dr Rajinder Pal Singh, the surgeon who carried out the double-transplant, also informed the court that the CMV-status of the patient was not considered a priority during the transplant surgery.

Outcomes of the court hearing

Recording a narrative verdict, the coroner Zak Golombeck stated there were a ‘number of missed opportunities’ in checking the CMV status of Mr Smith. He said: “The CMV status (of the donor organs) was listed on the Electronic Offering System but not on the list. The (handover) email didn’t, as it should’ve done, refer to the CMV status or EOS form. The consultant didn’t cross-check to action post-operative care.”

If it had been ‘recorded correctly” Mr Smith would have received the correct medication, said Mr Golombeck.

Further to this, Mr Golombeck issued a Regulation 28 report following the inquest, stating what improvements need to be made. The report recommended that the trust introduces a formal policy for checking the CMV status of a donor to be cross-checked through the process of surgery. Regulation 28 also recommended that patients are informed about the CMV status of the donor prior to giving consent to the operation.

Following our medical negligence case regarding Mr Smith, significant changes have been made to the processes for transplantation conducted by the Manchester University NHS Foundation Trust. These changes include (but are not limited to):

  • a more robust and comprehensive consent process regarding the communication of donor risks, particularly CMV status
  • following a formal check process post-transplantation which includes a thorough check of recipient documentation including the CMV status
  • redesigning the renal transplant patient discharge summary letter to incorporate relevant donor details including the donor and recipient CMV status

Mr Smith’s family, who we have stood by and represented during this ordeal, hope that ‘lessons would be learned’ from these fatal errors made by the Trust.

In a statement following the inquest, they said: “The past 20 months have been a nightmare for us. The evidence that was heard was extremely upsetting and disappointing as it showed the failure of the hospital to properly care for David, and the failure of the hospital’s systems which led to the errors which ultimately led to David’s death.”

We appreciate that this has been a difficult time for Mr David John Smith’s family and we feel honoured to have had the opportunity to represent them during this case of medical negligence.

Further details of this case can be viewed in this Manchester Evening News article.

Contact us for clinical negligence representation

If you feel that you may have suffered as a result of medical negligence, please reach out to our expert team here at Ten Legal.

In the unfortunate event that a medical diagnosis or treatment goes wrong resulting from a lack of judgement or incompetence of a medical professional, it is important for you to have access to legal assistance to support your case.

Our expert medical negligence lawyers have a proven track record in ensuring that the clinical negligence claimants we represent receive the compensation, justice that they are rightfully entitled to.

It is best to seek specialist advice as soon as possible after the incident. So, if you feel you may have been affected as a result of negligent medical treatment, you can call us on 0161 402 0213 for a free no-obligation consultation.