NHSBT adopt
measures to avoid another error occurring
A detailed review into how and why errors were made in recording
the donation wishes of new would-be organ donors has been
published today. It praises NHS Blood and Transplant for its
sensitive handling of the incident, but concludes that errors
could have been avoided if more robust procedures had been in
place in 1999 when the error was made.
Sir Gordon Duff, who conducted the review, found that the error
originated when faulty data conversion software was used by UK
Transplant to upload data on donation wishes from the Driver and
Vehicle Licensing Agency (DVLA) when it moved to a new computer system.
The review also outlines the remedial action taken by NHSBT and
the actions taken to prevent a recurrence. Sir Gordon has
concluded that once the error was identified and brought to the
attention of NHS Blood and Transplant’s senior managers it was
handled efficiently and sensitively.
With over 17 million registrants, there is a growing need for the
register to become more interactive. Sir Gordon recommends that
the longer-term solution is to create a more secure, interactive
system with better data verification and cross reference functions
and that NHSBT should take this forward as soon as resources allow.
His other recommendations include:
• that NHS Blood and Transplant should continue to operate the
current register but with a greater attention to sampling and
cross referencing which will minimise the risk of this happening again;
• all external forms on which people are asked to agree to donate
organs should collect information in a uniform way
• the practice of writing to all registrants to thank them for
agreeing to be an organ donor, and to give them the opportunity to
report any errors should continue;
• NHS Blood and Transplant should invite a third party
experienced in secure database management to review its new controls.
Sir Gordon Duff said
"Organ transplantation is a much needed life-saving procedure.
"People who generously agree to donate their organs
should be reassured that the error has been dealt with effectively
and that steps have been taken to minimise the risk of it
happening again.
“The current organ donor register, though still capable of being
an effective tool, has some inherent constraints. I have therefore
recommended that as soon as resources allow, NHS Blood and
Transplant should design and commission a new register which will
be better equipped to deal with the operational demands now placed
on it"
Responding to the publication of the review Public Health
minister Anne Milton said
“Organ transplants save lives. However, the system relies on the
generosity of people willing to donate.
“I would like to thank Sir Gordon for his work on producing this
clear report. It is reassuring to hear that NHS Blood and
Transplant handled the situation well once problems were
identified.
“Organ Transplants are vital and I know that NHS Blood and
Transplant will make sure such a situation never arises again.”
Notes for Editors
1. For Further enquiries please contact the DH Newsdesk on 0207
210 5221.
2. The full report can be found here: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicati onsPolicyAndGuidance/DH_120563
3. The organ donor register (ODR) is a computer database enabling
people to make their wishes on organ donation known during their
lives, potentially also saving their families from having to make
decisions at a time of great distress.
4. NHS Blood and Transplant (NHSBT) manage the ODR, and several
outside sources, including the Driver and Vehicle Licensing Agency
(DVLA), feed into it (there is an option to volunteer for organ
donation on the driving licence application form).
5. There are 17,087,646 registrants on the ODR and the error
likely occurred in January 1999, potentially affecting 992,424 records.
6. Twenty-five families were actually affected by the error when
consenting to organ donation by a deceased family member.
Contacts:
Department of Health
Phone: 020 7210 5221
NDS.DH@coi.gsi.gov.uk