VIChospital

Finding into death of Karen Elizabeth Wilkinson

Deceased

Karen Elizabeth Wilkinson

Demographics

44y, female

Coroner

Coroner Audrey Jamieson

Date of death

2007-01-01

Finding date

2013-05-07

Cause of death

Lymphocytic choriomeningitis virus (LCMV)-like virus infection following failed renal transplant

AI-generated summary

A 44-year-old woman died on 1 January 2007, six days after receiving a cadaveric renal transplant. She was one of three organ recipients from the same donor who died within six days of each other from a novel lymphocytic choriomeningitis virus-like arenavirus transmitted via the donor organs. The virus was unknown at the time of transplantation and could not have been detected by standard screening. Key clinical lessons include: the importance of inter-hospital communication when multiple recipients receive organs from the same donor to identify common complications earlier; ensuring transplant teams receive unfiltered donor information directly rather than through telephone relay; considering donor exposure history and systemic symptoms during screening; and improving family communication throughout critical illness. While earlier communication might have enabled faster diagnosis, the outcome was not altered, and the deaths were not foreseeable or preventable given available knowledge in 2006.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

transplant medicinenephrologyinfectious diseaseshepatology

Error types

communicationsystem

Clinical conditions

lymphocytic choriomeningitis virus infectionarenavirus infectionend-stage renal failuregraft failuresepsisencephalopathyadult polycystic kidney disease

Procedures

renal transplantorgan retrievalnephrectomy of failed transplant

Contributing factors

Novel arenavirus transmitted via donor organ
Donor with undiagnosed LCMV-like virus infection
Lack of inter-hospital communication between recipient teams post-transplant
Information relay loss through telephone rather than direct document access
Donor with severe renal artery atherosclerosis
Donor hepatitis B core antibody positive status
Post-operative sepsis and graft failure

Coroner's recommendations

DonateLife be authorised to extend liaison role in post-transplant period to accept responsibility for intra and inter-hospital communication regarding progress and complications of recipients where multiple organs from one donor are transplanted
DonateLife commence liaison with transplant teams 7 days post-operatively and continue every 48 hours thereafter until discharge of recipients
Hospitals nominate a designated contact person for DonateLife to communicate/liaise with on each recipient organ transplant procedure
Transplant teams should have direct access to Confidential Donor Referral Forms (CDRF) rather than filtered telephone relay to avoid information loss
Donors should be screened by enquiry regarding contact with rodents/hamsters given LCMV identified in such populations
Improved family communication in plain language during prolonged, complicated, and critical care

Full text

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Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

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