Coronial
VIChospital

Finding into death of Carmelina Rachela Sirianni

Deceased

Carmelina Sirianni

Demographics

63y, female

Coroner

Coroner Audrey Jamieson

Date of death

2007-01-07

Finding date

2013-05-07

Cause of death

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

AI-generated summary

A 63-year-old woman received a renal transplant from a cadaveric donor who had died of cerebral hemorrhage. She developed delayed graft function and deteriorated post-operatively, ultimately dying from a novel lymphocytic choriomeningitis-like virus (LCMV) transmitted via the donor organ. The donor and all three recipients of his organs died within days of each other. While the screening process was reasonable for the era, clinical lessons include: the need to improve direct access to complete donor referral forms by transplant teams (rather than filtered telephone communication); inquiry about donor contact with rodents/hamsters (potential LCMV vector); and robust post-transplant inter-hospital communication when multiple recipients receive organs from one donor. Family communication about the recipient's deterioration was inadequate. The death was neither foreseeable nor preventable at the time, as this novel arenavirus was unknown and no screening test existed.

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

Specialties

nephrologytransplant medicineinfectious diseasesmicrobiology

Error types

communicationsystem

Clinical conditions

lymphocytic choriomeningitis virus infectionarenavirus infectionacute tubular necrosisdelayed graft functionpost-transplant infectionsepsisencephalopathy

Procedures

renal transplantationorgan retrievalrenal biopsykidney excisionhemodialysis

Contributing factors

  • Transmission of novel arenavirus via donor organ
  • Delayed graft function due to acute tubular necrosis
  • Lack of real-time access to complete donor information by transplant team
  • Filtered telephone communication of donor referral information
  • Delayed inter-hospital communication regarding common deterioration of recipients
  • Inadequate family communication regarding patient deterioration

Coroner's recommendations

  1. DonateLife should 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/complications of donor organ recipients when there are multiple recipients from one donor
  2. DonateLife should commence liaison with transplant teams seven days post-operatively and continue communication every 48 hours thereafter until discharge of recipients
  3. Hospitals should nominate a designated contact person for DonateLife to communicate/liaise with on each occasion of organ transplant
  4. Consideration should be given to enquiring whether donors have contact with rodents/hamsters (potential LCMV vectors) as part of donor screening
  5. Transplant teams should have direct access to complete Confidential Donor Referral Forms (CDRFs) rather than relying on filtered telephone communication from donor coordinators
Full text
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