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Doctors not to blame for transplant deaths.

Doctors were not to blame for the treatment of two transplant patients who died after their kidneys were infected with “exceedingly rare” parasitic worms, an inquest has ruled.

Assistant coroner Christopher Wooley said both Robert “Jim” Stuart and Darren Hughes were aware of the risks of the operation and gave full consent for the transplants at the University Hospital of Wales (UHW), Cardiff in November 2013.

Mr Stuart, 67, from Cardiff, and Mr Hughes, 42, from Bridgend, underwent the organ swap operation and died two days apart from inflammation of the brain two weeks later.

Both retired business developer Mr Stuart and father-of-six Mr Hughes contracted the rare nematode worm from their donor in the first human-to-human transmission.

A post-mortem revealed the pair died from the infection  Meningeoencephaltis caused by a parasitic worm known as Halicephalobus Gingivalis.

The inquest heard that their alcoholic donor, 39, had cirrhosis of the liver and died of meningitis and septicaemia on November 29, days before the kidney transplants took place.

Transplant units in Leeds, Newcastle, Glasgow, and Sheffield were among those who turned down the kidneys before the UHW accepted them.

Doctors thought the donor had died from “suspected meningitis”, but believed the risk of transmission was low. /more...

Argiris Asderakis, the consultant transplant surgeon responsible for their operations, said he was confident both patients would recover from the kidney operations even though other transplant centres had dismissed the organs as unfit for use.

But Cambridge professor Christopher Watson, part of a three-person panel asked to review the case, told the inquest he would not have used the kidneys.

Mr Wooley, recording a narrative verdict, said both men faced a “significant risk of dying” on dialysis if they had not undergone the procedures.

Mr Wooley said there was nothing untoward in UHW transplant surgeon Argiris Asderakis accepting kidneys from someone suspected of dying from meningitis. But he said the surgeon carrying out the operations could have requested more information about the donor.

NHS figures show that over the past 10 years there have been 52 patients with undiagnosed meningitis becoming organ donors.

In the case of Robert Stuart and Darren Hughes, Mr Wooley said: “The kidneys had been rejected by several other transplant centres before they were accepted, either because of poor function or because of the donor’s cause of death.

“They were not rejected because of the Halicephalus nematode, or accepted in spite of it, as this organism is almost unknown to medical science and there was no test for it in the circumstances of the transplant.

“Robert James Stuart ...and Darren Hughes died from the unintended consequences of necessary medical intervention.”

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