An independent review into how the wrong organs were removed from 25 donors in the UK has found that faulty computer software lay at the heart of the problem.
The review, led by Professor Sir Gordon Duff, concludes that the error originated in faulty data conversion software that was used to upload data on donation preferences from the Driver and Vehicle Licensing Agency to NHS Blood and Transplant.
The problem only came to light when NHSBT, which now runs the register, wrote to donors to check their preferences. Many donors reported that the information it held was incorrect.
The review recommends that the “Organ Donor Register create a secure, interactive system with inherent data verification and cross-referencing functions,” that would allow individuals to check and change their own data.
It says this should be done “as soon as funding permits.” It adds that the current system must be made “robust in terms of the accuracy of information held, with systematic sampling and checking of data for accuracy against source documents."
Furthermore, it recommends that all external forms on which people are asked to agree to donate organs should collect the same data in the same way in order to reduce the future risk of error in transposing data from external feeds onto the ODR.
Sir Gordon added: “With the benefit of hindsight, it would seem that the transcription error might have been avoided altogether, or identified earlier by systematic data verification procedures.
“However, it is important to remember that the ODR was originally set up to monitor the success of awareness-raising campaigns, and not as an operational tool.”
The review is aimed at restoring and increasing public confidence in and ensuring that it can meet broader requirements now and in the future.
A spokesperson for NHSBT said: “NHSBT welcomes Professor Sir Gordon Duff’s independent review into mis-recording of data on the ODR, and his finding that the issue was handled with the appropriate level of urgency, diligence and sensitivity.
“NHSBT sincerely regrets that the error was not uncovered earlier and that the donations of 25 individuals were affected by it. We would like to take this opportunity to reiterate our unreserved apologies to the families of those people.”