NHS Blood and Transplant Service
Noted
No AI summary available.
View full response
Dear HM, Assistant Coroner A Farrow Re: Regulation 28 Report, 27th February 2026 On behalf of NHS Blood and Transplant (NHSBT), we would first like to take this opportunity to offer our condolences to the family and friends of Maisie Kate Almond, following her death at the Leeds General Infirmary, Leeds on 2nd October 2024.
We note the matters of concern;
1. Evidence from a consultant paediatric hepatologist that there is a national shortage of donor livers generally and particularly for children in the “super urgent” category.
2. The clinical guidance not to utilise cardiac death donor livers in such cases due to the poor historical outcomes has narrowed the pool of suitable donor livers to those arising from brain deaths. Altruistic living liver donations are generally not available for super urgent cases.
3. The number of donor livers has reduced by a third and the effect is that, historically, a donor liver could be expected to be made available within 48 hours, the wait has now extended to up to a week. That delay gives rise to a clear risk that lives will be lost due to the unavailability of suitable donor organs. We will respond to the matters of concern as noted above as 1,2 & 3.
1. National shortage of donor livers generally and particularly for children in the “super urgent” category The UK, like many other countries, is facing ongoing challenges with both donor numbers and consent rates. Although organ donation activity had been steadily recovering in the years following the pandemic, this progress has been offset by a continued decline in consent rates. The most recent UK data for 2024–2025 shows that the pool of potential donors is now 18% smaller than before the pandemic, and family consent rates have fallen from 68% to 59%. As a result, April of last year saw the highest number of people on the UK transplant waiting list ever recorded. While the number of patients waiting is now slowly beginning to decrease, the reality remains that there are still not enough donor livers available to meet clinical need. The three paediatric liver transplant units in the UK regularly split suitable adult livers to transplant children. In the UK, split liver transplantation (usually for one child and one adult) is always prioritised from, high-quality, donors after neurological death testing (DBD) who are Patient Safety Team Newcastle Blood Centre Holland Drive Barrack Road Newcastle upon Tyne NE2 4NQ
A1
NHS Blood and Transplant is a Special Health Authority within the National Health Service.
aged <45 years and weight < 90 kg. These livers are always offered to centres for splitting to maximise organ usage for the paediatric population. The donor profile in the UK has changed significantly, with donors now generally being older— the current average age is 53. In addition, donor BMI has increased. These shifts, combined with a smaller and less healthy donor pool, reduced family consent rates, and circumstances of death that limit donation, have collectively decreased the number of livers suitable for splitting.
2. DCD Livers in Paediatric liver transplantation We have also seen a shift in donor type across the UK, with an increasing proportion of donors after circulatory death (DCD) compared with donors after brain death (DBD) over the past two years. This trend has not been observed previously, and it appears to be continuing. Notably, similar patterns are being reported in other countries. As a result of this shift, fewer livers now meet the criteria for splitting, as DCD livers are not routinely split due to the increased risk of graft failure. While all donor types carry some degree of risk, splitting a DCD liver presents particular challenges. Nevertheless, DCD donors remain an important source of organs across the UK. Advances in emerging technologies may in time support the safe splitting of DCD livers, but at present, national guidance continues to recommend splitting only DBD livers. Historically splitting a DCD liver is associated with high rates of biliary complications and small for size ischaemia seen across the world. Isolated case reports, conference reports and centre experience from Spain and Italy suggest feasibility of splitting DCD livers from young donors (<40) with short functional warm ischaemia and prolonged stable Normothermic Regional Perfusion (NRP), with good lactate clearance. This is not evidenced across the world as it is not routinely done, but when it is facilitated, it is done through in-situ splitting. DCD-NRP splitting is currently regarded as experimental and any such activity in the UK will sit under a service evaluation needing innovation governance and possible research ethics. As NRP is rolled out across all retrieval teams DCD-NRP splitting can be evaluated
3. Reduction in donor livers and extended waiting time
Points 1 and 2 above explain the reasons for the current shortage of donor organs.
It is impossible to predict the availability of a liver for the super urgent category both adult and children. For children we are usually waiting for a suitable liver to enable liver splitting or a liver to become available from a child or young adult suitably sized match to enable transplantation. Unfortunately, the ongoing shortage of donor organs has further extended waiting times, and in this case, a suitable liver did not become available on time.
Action being taken NHSBT is working to ensure that we address the challenges in the donation pathway. Some of the various initiatives underway include but are not limited to:
• Marketing, Communication, and Societal Action: Continue with strategies to raise awareness and improve public support for organ donation.
• Clinical Practice: Enhancements in clinical protocol and practice to widen the pool of potential donors being reviewed. Alongside this, work to look at neurological death testing improving access to, and consistency of testing has commenced. This work will endeavour to increase the number of DBD donors in the UK, with the ultimate of ensuring more organs can be available for liver splitting and cardiothoracic transplantation. Streamlining the family approach to enhance consent rates being reviewed. A2
NHS Blood and Transplant is a Special Health Authority within the National Health Service.
• Coroners working group: continue to collaborate with HM Coroners, Police, Forensic Pathologists and Medical Examiners to ensure we can maximise the number of potential organ donors, where possible. This PFD is scheduled for discussion at the next meeting.
• Increased use of novel technologies for DCD donation.
• Introduction of Assessment and Recovery Centres (ARCs) for organ donation. ARCs improve organ donation by utilising specialized machine perfusion to assess, repair, and recondition "marginal" organs previously deemed unsuitable for transplant. These centres aim to increase the number of viable organs, reduce transplant waiting lists, and allow for safer, high-quality organ transplantation.
We are very sorry that the call for transplant did not come for this child. We have shared the PFD with the wider donation community to reinforce the importance of considering organ donation in all appropriate clinical circumstances. Please do not hesitate to contact us should you have any further questions about our service.
Your sincerely
Director of Organ and Tissue Donation and Transplantation
Medical Director Organ and Tissue Donation and Transplantation
A3
We note the matters of concern;
1. Evidence from a consultant paediatric hepatologist that there is a national shortage of donor livers generally and particularly for children in the “super urgent” category.
2. The clinical guidance not to utilise cardiac death donor livers in such cases due to the poor historical outcomes has narrowed the pool of suitable donor livers to those arising from brain deaths. Altruistic living liver donations are generally not available for super urgent cases.
3. The number of donor livers has reduced by a third and the effect is that, historically, a donor liver could be expected to be made available within 48 hours, the wait has now extended to up to a week. That delay gives rise to a clear risk that lives will be lost due to the unavailability of suitable donor organs. We will respond to the matters of concern as noted above as 1,2 & 3.
1. National shortage of donor livers generally and particularly for children in the “super urgent” category The UK, like many other countries, is facing ongoing challenges with both donor numbers and consent rates. Although organ donation activity had been steadily recovering in the years following the pandemic, this progress has been offset by a continued decline in consent rates. The most recent UK data for 2024–2025 shows that the pool of potential donors is now 18% smaller than before the pandemic, and family consent rates have fallen from 68% to 59%. As a result, April of last year saw the highest number of people on the UK transplant waiting list ever recorded. While the number of patients waiting is now slowly beginning to decrease, the reality remains that there are still not enough donor livers available to meet clinical need. The three paediatric liver transplant units in the UK regularly split suitable adult livers to transplant children. In the UK, split liver transplantation (usually for one child and one adult) is always prioritised from, high-quality, donors after neurological death testing (DBD) who are Patient Safety Team Newcastle Blood Centre Holland Drive Barrack Road Newcastle upon Tyne NE2 4NQ
A1
NHS Blood and Transplant is a Special Health Authority within the National Health Service.
aged <45 years and weight < 90 kg. These livers are always offered to centres for splitting to maximise organ usage for the paediatric population. The donor profile in the UK has changed significantly, with donors now generally being older— the current average age is 53. In addition, donor BMI has increased. These shifts, combined with a smaller and less healthy donor pool, reduced family consent rates, and circumstances of death that limit donation, have collectively decreased the number of livers suitable for splitting.
2. DCD Livers in Paediatric liver transplantation We have also seen a shift in donor type across the UK, with an increasing proportion of donors after circulatory death (DCD) compared with donors after brain death (DBD) over the past two years. This trend has not been observed previously, and it appears to be continuing. Notably, similar patterns are being reported in other countries. As a result of this shift, fewer livers now meet the criteria for splitting, as DCD livers are not routinely split due to the increased risk of graft failure. While all donor types carry some degree of risk, splitting a DCD liver presents particular challenges. Nevertheless, DCD donors remain an important source of organs across the UK. Advances in emerging technologies may in time support the safe splitting of DCD livers, but at present, national guidance continues to recommend splitting only DBD livers. Historically splitting a DCD liver is associated with high rates of biliary complications and small for size ischaemia seen across the world. Isolated case reports, conference reports and centre experience from Spain and Italy suggest feasibility of splitting DCD livers from young donors (<40) with short functional warm ischaemia and prolonged stable Normothermic Regional Perfusion (NRP), with good lactate clearance. This is not evidenced across the world as it is not routinely done, but when it is facilitated, it is done through in-situ splitting. DCD-NRP splitting is currently regarded as experimental and any such activity in the UK will sit under a service evaluation needing innovation governance and possible research ethics. As NRP is rolled out across all retrieval teams DCD-NRP splitting can be evaluated
3. Reduction in donor livers and extended waiting time
Points 1 and 2 above explain the reasons for the current shortage of donor organs.
It is impossible to predict the availability of a liver for the super urgent category both adult and children. For children we are usually waiting for a suitable liver to enable liver splitting or a liver to become available from a child or young adult suitably sized match to enable transplantation. Unfortunately, the ongoing shortage of donor organs has further extended waiting times, and in this case, a suitable liver did not become available on time.
Action being taken NHSBT is working to ensure that we address the challenges in the donation pathway. Some of the various initiatives underway include but are not limited to:
• Marketing, Communication, and Societal Action: Continue with strategies to raise awareness and improve public support for organ donation.
• Clinical Practice: Enhancements in clinical protocol and practice to widen the pool of potential donors being reviewed. Alongside this, work to look at neurological death testing improving access to, and consistency of testing has commenced. This work will endeavour to increase the number of DBD donors in the UK, with the ultimate of ensuring more organs can be available for liver splitting and cardiothoracic transplantation. Streamlining the family approach to enhance consent rates being reviewed. A2
NHS Blood and Transplant is a Special Health Authority within the National Health Service.
• Coroners working group: continue to collaborate with HM Coroners, Police, Forensic Pathologists and Medical Examiners to ensure we can maximise the number of potential organ donors, where possible. This PFD is scheduled for discussion at the next meeting.
• Increased use of novel technologies for DCD donation.
• Introduction of Assessment and Recovery Centres (ARCs) for organ donation. ARCs improve organ donation by utilising specialized machine perfusion to assess, repair, and recondition "marginal" organs previously deemed unsuitable for transplant. These centres aim to increase the number of viable organs, reduce transplant waiting lists, and allow for safer, high-quality organ transplantation.
We are very sorry that the call for transplant did not come for this child. We have shared the PFD with the wider donation community to reinforce the importance of considering organ donation in all appropriate clinical circumstances. Please do not hesitate to contact us should you have any further questions about our service.
Your sincerely
Director of Organ and Tissue Donation and Transplantation
Medical Director Organ and Tissue Donation and Transplantation
A3