Woman Dies After Hospital Gives Her Incompatible Heart

Hospital conducts critical blood serum test, but doesn't wait for the results before conducting the transplant, relying on 'virtual' test that fails to detect compatibility problem.

A heart transplant patient died this month after staff at Beilinson Hospital, Petah Tikva, failed to fully test for organ compatibility and she received an incompatible heart, according to a National Transplant Center report.

The Health Ministry directed the Transplant Center to investigate after the death of the 49-year-old woman - who suffered from a serious heart condition - a day and a half after her heart transplant on January 18.

Haaretz has obtained a copy of the report, which states that medical staff at Beilinson only conducted a computerized "virtual" examination of compatibility. They did not conduct a blood serum laboratory test of white cells to check whether the recipient was likely to reject the organ - even though a doctor in charge of the laboratory at Beilinson warned on the form the hospital sent to the National Transplant Center that such a test was required before conducting the procedure.

The "virtual" test, which is considered adequate in certain circumstances, did not show any danger to the patient. The hospital did conduct a blood serum test later, but did not wait for the results before conducting the transplant.

The medical team at Beilinson had the possibility of consulting with the hospital's own organ laboratory and the National Transplant Center's lab at Sheba Medical Center, Tel Hashomer, but did not do so.

Tests conducted after the patient died showed very high levels of antibodies, which make it almost certain that the transplanted heart was rejected.

The Health Ministry decided to appoint an investigative committee, after the Transplant Center held a meeting at Beilinson with the staff to examine the incident.

There are no clear regulations in Israel stating when it is sufficient to only conduct a virtual compatibility exam before a heart transplant, and when it is necessary to wait for blood serum tests.

The Health Ministry said: "The matter was examined in depth by a professional team and representatives of the ministry's management." After a discussion, the ministry decided to appoint a committee to study the matter, it said.

Beilinson Hospital said it had not received the report yet and therefore could not comment on its contents. However, it did say it had learned of the report from the press.

"Hospital management supports the [medical] team that dealt with the heart transplant and acted based on the accepted standards in Israel and the world," a spokesperson said, adding, "A committee to examine the matter was established by the Health Ministry, and it is necessary to wait for the results of its examination and recommendations."

The National Transplant Center reported that 96 Israelis were waiting for heart transplants at the beginning of 2012, and 17 Israelis died in 2011 while waiting for such transplants.

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