HIV-tainted organ transplant blamed on team leader and techs

TAIWAN - The Department of Health (DOH) yesterday issued the investigation report on the HIV-tainted organ transplant conducted by the National Taiwan University Hospital (NTUH), which laid blame on the hospital's transplant team leader and lab technicians.

"The unsuitable medical personnel will be transferred from their current positions to receive further professional training," Health Minister Chiu Wen-ta announced yesterday at the Legislative Yuan while reporting on the result of the HIV-transplant investigation.

As a result of the NTUH's Aug. 24 organ transplants from an HIV-carrier, one of the five patients who had received an organ is currently hospitalized in the intensive care unit, another one in a regular ward, while the other three had been discharged from the hospital. Recent HIV test reports indicated negative results for all five, Chiu said.

Ko Wen-che, leader of NTUH's organ transplant team, was accused of having violated the Physicians Act, while the skills and attitudes of NTUH's lab technicians were charged as failing to meet professional standards, according to the investigation report issued by the DOH.

Ko had admitted when interviewed on Aug. 31 that he had not personally interpreted the test results of the organ donor, as revealed in the DOH report; rather, Ko had allowed a coordinator to key test results directly into the transplant center's database, the basis on which later transplants were carried out.

With Ko's negligence listed in detail in the report, the ad hoc investigation team has referred the case to the Taipei City Government Department of Health's Medical Disciplinary Committee, which would decide on the punishments Ko is to receive.

Also listed as unprofessional in the investigation report were NTUH's lab technicians, who had all had prior knowledge of the organ donor's HIV status yet did not exchange this information with the coordinator.

In addition, that a lab technician had asked a colleague to take over phone conversations with the coordinator for the reason that "the coordinator had an attitude," was unacceptably unprofessional, the report noted.

While Chiu advised the NTUH organ transplant team to revise its standard operating procedures (SOP) and better monitor its crisis management, he acknowledged that "the DOH will take up the administrative responsibilities" over the case.

DOH 'lacks self-reflection abilities': Ko

"The DOH lacks self-reflection abilities," Ko commented after reading the HIV transplant investigation report, yesterday, pointing out that nowhere in the entire report were the DOH's faults in the incident mentioned, let alone the issues revolving around the organization of the organ donation and transplantation center.

There are loopholes in NTUH's organ donating process, Ko acknowledged; however, "this is how all hospitals in Taiwan have been doing," he claimed, explaining that there does not exist any official versions of the procedures to use as reference in Taiwan.

All of the past CEO's of Taiwan's organ donation and transplantation center had held concurrent positions elsewhere, and few people who work in the center had medical backgrounds, he added, pointing out that this incident should not lead to the "stepping down" of a higher official, but an overall structural reformation in the organization of the center.

If all that comes out of sacrificing by taking up the blame over the incident is others' opportunity to brush off responsibilities, cover up the truth, and continue to "slack off," then so doing is completely worthless, Ko concluded.