In April, I blogged about the discovery of a software problem that existed for over 10 years without being noticed in the UK's National Health Service's (NHS) Blood and Transplant (NHSBT) Special Health Authority organ donation system. The problem caused the organ donation wishes of some 800,000 people on the NHS Organ Donor Register (ODR) to be in error. At the time, there were at least twenty cases identified where organs were taken without proper consent.
Then UK Health Secretary Andy Burnham expressed his deep "regrets" over the distressed caused, and asked Professor Sir Gordon Duff of Sheffield University to carry out a review of the situation to prevent it from happening again.
A story in today's London Daily Mail says Sir Gordon's review (PDF here) found that a total of 25 improper organ donations occurred - not many considering the number of people and length of time involved.
Sir Gordon found that the reason for the error was that when a new organ donation computer system was installed by the NHS in 1999, the organ donation check boxes on the form were not linked correctly to what the computer system was programmed to read. So someone indicating that they were willing to donate their corneas were actually agreeing to having their heart removed instead.
Sir Gordon's report goes into the details of what happened, why it took so long to be discovered, and why (luckily) more incorrect organ donations did not happen, which always puzzled me. I suggest you give the report a read: it makes for an interesting case study starring all the usual suspects: lack of clear specifications, poor end-to-end testing, etc.
Sir Gordon, the Daily Mail says, "recommended that as soon as resources allow, NHS Blood and Transplant should design and commission a new register which will be better equipped to deal with the operational demands now placed on it."
For its part, the NHSBT said that:
"We accept in full the recommendations of Professor Sir Gordon Duff, which will contribute significantly to strengthening the ODR and public confidence in it as a way to record organ donation wishes. "
It also "sincerely regrets that the error was not uncovered earlier."
Robert N. Charette is a Contributing Editor to IEEE Spectrum and an acknowledged international authority on information technology and systems risk management. A self-described “risk ecologist,” he is interested in the intersections of business, political, technological, and societal risks. Charette is an award-winning author of multiple books and numerous articles on the subjects of risk management, project and program management, innovation, and entrepreneurship. A Life Senior Member of the IEEE, Charette was a recipient of the IEEE Computer Society’s Golden Core Award in 2008.