Inquest into transplant death

Leigh Robbins died, aged 53, in March 2016 less than three months after an operation at Churchill Hospital, in Oxford, to transplant a pancreas.

At the end of a three-day inquest Oxford Coroner’s Court on Thursday, June 1, the assistant coroner for Oxfordshire Rosamund Rhodes-Kemp recorded a narrative conclusion, saying that Leigh had died from complications of cytomegalovirus (CMV), an infection he had developed as a result of undergoing the transplant.

She said, however, ‘on balance’, the death could have been prevented through the administration of correct antiviral treatment.

The court heard evidence that Leigh had suffered as a result of a series of failings in his care including a mix-up of blood samples belonging to two organ donors and failures to act upon blood test results which were positive for CMV infection.

Despite evidence heard at the inquest that steps have already been taken, the coroner will now write to the organisations involved in the transplant process to clarify whether more can and should be done to prevent a reoccurrence.

Following Leigh’s death, his wife Rebecca looked to medical negligence lawyers at Irwin Mitchell for help.

Guy Forster, from Irwin Mitchell’s medical negligence team, said: “The series of failings that have been revealed as part of our investigations and at the inquest itself have raised a number of very serious concerns in relation to both the systems in place and treatment provided to Leigh.”

Rebecca Robbins, 37, said: “We are all hugely concerned by the findings of the inquest and it is devastating to know that, if things had been done differently, Leigh’s death could have potentially been prevented.

“Whilst nothing will ever be able to change what has happened, our only hope as a family now is that lessons can be learned to ensure that no one else faces the failings that led to Leigh’s death.”

She added: “It simply cannot be allowed to happen again.”

Following the inquest, Dr Tony Berendt, medical director of Oxford University Hospitals NHS Foundation Trust, said the trust had offered its ‘sincere apologies’ to the family, adding: “Since [the death] we have looked very carefully at our processes and we have made several significant changes to our procedures.”

John Forsythe, associate medical director for organ donation and transplantation at NHS Blood and Transplant (NHSBT), said the trust offered its ‘unreserved apologies’ to the family.

He added: “We have examined our processes in great detail and changes to working practices have been implemented to help prevent a similar event happening again.

“Comprehensive investigations were undertaken by the all the organisations involved, but we have not been able to establish whether or not the microbiology samples became mixed up whilst NHSBT were handling them.”

A Public Health England spokesman said the organisation ‘profoundly regret[s]’ its part in the death, adding: “We concluded our internal investigation in September last year and rapidly implemented a number of technical recommendations on the processing and storage of samples.

“We also issued a risk alert to our wider network of regional laboratories requiring them to review their systems and processes accordingly, which they have acted on.”