*2. BACKGROUND*

*2.1 On 4 September 2008, the Director of Cardiothoracic Transplantation at Harefield Hospital, Professor Gilles Dreyfus, told the NSC Team that:* 

*between 17 July and 3 September 2008 four consecutive heart transplant patients transplanted in July and August died within 30 days* 

*RBHT had begun an urgent internal review of these events.* 

*2.2 These consecutive deaths were enough for the monthly sequential analysis carried out by NHS Blood and Transplant (NHSBT) statisticians to signal a subsequent alert (see paragraph 3.12 and Appendix A). Internal audit prompted Professor Dreyfus to inform the NSC Team without delay prior to this analysis being reported.* 

*2.3 The RBHT internal review investigated these four deaths and three other deaths beyond 30 days in patients transplanted earlier in 2008. Seven (47%) of the 15 heart patients transplanted this year have died. The Internal Review is considered later in this report.* 

*2.4 These events followed a period of low 30- and 90-day heart transplant mortality in 2006 and 2007. A statistical analysis of heart transplant outcomes carried out by the UK Cardiothoracic Transplant Audit (UKCTA) is summarised below in Section 3 of this report.* 

*2.5 Early mortality following lung transplant has been low at Harefield this year: one death in 21 patients transplanted in 2008 (4.8%).* 

*2.6 In 2005, the National Specialist Commissioning Advisory Group (NSCAG) undertook an* 

Extracts as follows (Please note that all figures referred to have not been included in these

http://www.specialisedservices.nhs.uk/document/review-recent-outcomes-in-heart-

*REPORT OF THE EXTERNAL REVIEW OF RECENT OUTCOMES IN THE HEART* 

*1.1 This report summarises an external review of a higher than expected number of deaths following heart transplants performed at Harefield Hospital in July and August 2008.* 

*1.2 The review was an agreed joint approach between the National Specialised Commissioning Team (NSC Team) and the Healthcare Commission (HCC). It was also agreed with the Royal Brompton and Harefield NHS Trust (RBHT). The HCC has reviewed the findings of this* 

*2.1 On 4 September 2008, the Director of Cardiothoracic Transplantation at Harefield Hospital,* 

*between 17 July and 3 September 2008 four consecutive heart transplant patients transplanted in* 

*2.2 These consecutive deaths were enough for the monthly sequential analysis carried out by NHS Blood and Transplant (NHSBT) statisticians to signal a subsequent alert (see paragraph 3.12 and Appendix A). Internal audit prompted Professor Dreyfus to inform the NSC Team without delay* 

*2.3 The RBHT internal review investigated these four deaths and three other deaths beyond 30 days in patients transplanted earlier in 2008. Seven (47%) of the 15 heart patients transplanted this* 

*2.4 These events followed a period of low 30- and 90-day heart transplant mortality in 2006 and 2007. A statistical analysis of heart transplant outcomes carried out by the UK Cardiothoracic* 

*2.5 Early mortality following lung transplant has been low at Harefield this year: one death in 21* 

*2.6 In 2005, the National Specialist Commissioning Advisory Group (NSCAG) undertook an* 

extracts but are available in the full report available at

transplant-service-at-harefield-hospital)*.* (NSCT, 2008)

*NATIONAL COMMISSIONING GROUP (NCG)*

*Professor Gilles Dreyfus, told the NSC Team that:* 

*RBHT had begun an urgent internal review of these events.* 

*year have died. The Internal Review is considered later in this report.* 

*Transplant Audit (UKCTA) is summarised below in Section 3 of this report.* 

*July and August died within 30 days* 

*prior to this analysis being reported.* 

*patients transplanted in 2008 (4.8%).* 

*1. INTRODUCTION* 

*2. BACKGROUND* 

*report.* 

*TRANSPLANT SERVICE AT HAREFIELD HOSPITAL (2008)* 

*external review of the Harefield service because of an above expected early mortality following both heart and lung transplants. In contrast to the present situation, this review followed a gradual but non-statistically significant increase in early mortality compared to other transplant centres. The 2005 review found no single explanation but considered the outcomes in 2005 were linked to system and process problems in donor assessment, organ retrieval and intra-operative care. Harefield implemented a series of actions recommended by its own internal review and the external review.* 

*2.7 Following completion of the RBHT internal review of deaths in 2008, the Trust, NSC Team and HCC agreed that an external review should be completed within one month by a heart transplant surgeon and a transplant cardiologist from other centres. If a suitable donor heart were to become available during the course of the review, the transplant team at Harefield would consult with the external reviewers before undertaking a transplant.* 
