Lung transplant patient dies after 'height error' sees surgeons force oversized organ into her chest

A lung transplant patient died after medical staff made a mistake in recording the height of the donor – and then failed to report the matter to the coroner.

A specialist nurse fed the wrong figure into the NHS transplant service’s computer system, leading surgeons to force an organ which was too big for the patient into her chest.



The exterior of the Harefield Hospital in west London where a woman died following a mistake by medical staff over a lung transplant

The mistake happened at Harefield Hospital in West London, where a similar incident in 2007 was followed by a two-year period in which managers took no action to suspend the consultant involved.



During that time the consultant bungled a heart bypass on an elderly man who bled to death and then lied to the patient’s family.



After the latest mistake, transplant service officials were told the death had been referred to the coroner but that he had decided not to hold an inquest.



They were also assured the woman’s family had refused permission for a post-mortem examination.



But it later turned out the coroner had not been informed, although he should have been as an inquiry concluded the death was caused by human error.



The woman, who was suffering from advanced bronchial disease, underwent a double lung transplant at Harefield last October. She was 151cm tall and the donor’s height was recorded electronically as 156cm.



The information was stored on the Electronic Offering System – the computerised organ-matching service run by the NHS Blood and Transplant Service (NHSBT).

The right lung was transplanted successfully but the left one had to be compressed to make it fit. And when a member of the transplant team checked the measurements later, it was discovered that the donor had actually been 165cm tall. After initially making progress, the woman developed pneumonia and died two months later.



Surgeons performing a heart transplant operation at the Harefield Hospital

NHSBT, which investigated the incident, said in a report: ‘The transplant surgeon considers that the size of the lungs was a significant contributory factor in the patient’s death.’



A doctor who has also served as a coroner told The Mail on Sunday: ‘It is usual for operation-related deaths to be referred to the coroner. But health care professionals are under no professional or legal obligation to do so.’



Katherine Murphy, chief executive of the Patients Association, said: ‘This must have been a terrible experience for the family.



'When attempts are made to cover up serious incidents like this, public and patient trust hits rock bottom.’



Hamzah Butt aged 16 from Sudbury,an active sportsman who underwent a heart transplant as a 10 day old baby at the Harefield Hospital, north west London. Hamzah is seen here at Harefield hospital Aged three.

Harefield Hospital would not comment on the case.



Anthony Clarkson, assistant director of organ donation at NHSBT, said the service had offered its sincere condolences to the woman’s family.



New checking systems have been introduced and heights are now recorded in both metric and imperial measures.

