Coronial
VIChospital

Finding into death of Gurpal Sandhu

Deceased

Gurpal Sandhu

Demographics

64y, female

Coroner

Coroner Audrey Jamieson

Date of death

2007-01-03

Finding date

2013-05-07

Cause of death

Lymphocytic choriomeningitis virus (LCMV)-like arenavirus infection, post liver transplant

AI-generated summary

A 64-year-old woman died on 3 January 2007 from a lymphocytic choriomeningitis virus (LCMV)-like arenavirus acquired through cadaveric liver transplantation. The donor had recently returned from Serbia with unexplained weight loss, lethargy, and headaches. Two other recipients of the same donor's organs also died from the same novel virus within 6 days. Post-hoc investigations identified this previously unknown arenavirus. The screening process at the time was reasonable and could not have prevented these deaths, as the virus was unknown and undetectable. Key clinical lessons include: improved inter-hospital communication about multi-recipient donor outcomes is essential to recognise clustering of symptoms sooner; donor-coordinated liaison should be systematized post-transplant; and families require regular, clear communication about deteriorating patients to reduce distress and anger. Early recognition of the common neurological deterioration might have prompted sooner investigation but would not have altered the fatal outcomes.

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

Specialties

transplant medicinehepatologynephrologyintensive careinfectious diseases

Error types

communicationsystem

Clinical conditions

arenavirus infectionpost-transplant infectionencephalopathic septic illnesssepticaemiaintra-abdominal wound infection

Procedures

cadaveric liver transplantationorgan retrievalsurgical drainage of infected haematoma

Contributing factors

  • Transmission of novel arenavirus via cadaveric organ donation
  • Donor had spent 3 months in Serbia with unexplained weight loss, lethargy, and headaches
  • Delayed inter-hospital communication regarding deterioration of multiple recipients from same donor
  • Lack of systematic post-operative communication between transplant teams receiving organs from same donor
  • Information from donor coordinator transmitted by telephone through multiple intermediaries, risking loss or filtering of critical details

Coroner's recommendations

  1. DonateLife be authorised by hospitals performing transplant surgery to extend their liaison role in the post-transplant period to accept responsibility for intra and inter-hospital communication regarding the progress and unusual symptoms or complications of donor organ recipients where there are multiple recipients from one donor
  2. DonateLife commence liaison with transplant teams seven days post-operatively and continue intra and inter-hospital communication every 48 hours thereafter until discharge of recipients
  3. On each recipient organ transplant procedure, the hospital should nominate a designated contact person for DonateLife to communicate and liaise with
  4. Enquiries should be made and recorded by the donor coordinator regarding recipients' contact with rodents or hamsters as potential LCMV exposure risk
  5. Confidential Donor Referral Forms should be made accessible online and centrally stored so transplant teams can review the original unfiltered information rather than receiving filtered telephone relay
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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