After the blood type of a South Carolina organ donor was incorrectly identified, a man in Charleston who'd received the donor's lungs died and another patient in Tennessee who received the liver was gravely injured. Both of their bodies rejected the donor's organs on the same day in late 2018.
Experts say the errors should never have happened.
A Charleston nonprofit called We Are Sharing Hope SC recovered and shipped the donor's lungs to the Medical University of South Carolina and sent the liver to a hospital in Nashville. One of 57 organ procurement organizations like it in the country, We Are Sharing Hope SC is the only one operating in most of this state.
Few things in medicine are considered as precious as a solid organ donation, especially from someone who has died. To mix up the match between the donor's and patient’s blood type is rare, experts say.
“That, in principle, should never happen,” said Dr. Bryan Whitson, a transplant surgeon and researcher at the Ohio State University Wexner Medical Center.
Allen Holliman had staked his hopes of surviving his incurable disease on the lung transplant he received in Charleston on Nov. 28, 2018. Though there is a policy in place making sure it’s notified of the worst medical mistakes, no one told the S.C. Department of Health and Environmental Control about the circumstances of Holliman’s death.
The case is an echo of another botched transplant at Duke University in 2003. That teenager's death captured national attention and brought about a reckoning for the organ-matching process.
The mistake that killed Holliman in Charleston has generated little attention, despite the similarity in circumstances. Two regulatory bodies said they would review the case when The Post and Courier started asking questions. The public wouldn’t know about Holliman's death at all if not for his wife’s lawsuit against the state's top academic medical center and We Are Sharing Hope SC.
A tough diagnosis
Allen and Michelle Holliman moved to Aiken in 2014 to find a slower pace of life down South, but that was hard for a gregarious man who thrived on interactions with others. The former owner of a limousine service, he became a real estate agent when they moved from Connecticut.
Allen’s diagnosis of pulmonary fibrosis came as a surprise. The condition has no known cause or cure and makes lung tissue thicken and stiffen. It becomes harder — and eventually impossible — to breathe over time.
Before long, Allen was wearing a breathing tube and carrying an oxygen tank, and the couple was making regular trips to MUSC in Charleston.
Allen refused to be deterred by the diagnosis.
“He had a lot of hope,” Michelle said.
His doctors didn’t expect him to live without a transplant, Allen wrote in an online fundraiser he started to gather the money he needed for a new set of lungs. The total cost of the transplant could be at least $280,000, according to one study. Although his insurance would cover the procedure, Allen was asking for $50,000 to help cover all the extra costs associated with recovery, including rent in Charleston and his medications.
Michelle remembers all the conversations about the risks and Allen’s chances of survival after transplant, which they understood would never be perfect.
“I've been a fighter for my whole life. I've worked hard for my family, my community, and my faith. I want to keep fighting,” Allen wrote on his GoFundMe page. “My two daughters, my wife, my brother and his family, and my friends are all supportive. With them, and God at my side, I feel that I have a good chance to live a longer life.”
Allen didn’t wake up for the phone call that came early one morning a few days after Thanksgiving in 2018. But Michelle heard it, and rushed to pick up the phone. It was the news they had been waiting for, and sooner than they hoped: A pair of lungs was available.
They rushed out the door to drive three hours to MUSC.
After arriving at the hospital, Allen posted on Facebook that the surgery was supposed to begin at 8 a.m. Friends shared their prayers for a safe procedure. As the medical team rolled him into the operating room, Allen flashed a smile and a thumbs-up to his wife.
“He probably was nervous, actually,” Michelle said. “But not to me.”
Only about a month after Allen Holliman won a spot on the transplant waiting list, someone was dying at Grand Strand Medical Center in Myrtle Beach. According to Michelle Holliman’s lawsuit, the medical team there gave the patient a massive blood transfusion in a bid to save his or her life.
Who this person was and why they died is confidential because of patient privacy rules.
We Are Sharing Hope SC, the organ network that operates in 44 of South Carolina's 46 counties, is the organization that picks up the phone when someone progresses to brain death at one of the state's hospitals.
The nonprofit ordered a lab to run tests on the donor’s blood. But because of the blood transfusion the patient had received, the results of the blood-typing test were inconclusive, according to court records.
Here, the process began to break down.
We Are Sharing Hope SC registered the donor's organs with the United Network for Organ Sharing, which looks for a match based on geography, blood type, age and other factors. Two blood tests confirming the donor's type are needed before making a match.
In this case, the organs were somehow registered with the national network as having type O blood. In fact, though, the blood was type A.
Whitson, the Ohio State surgeon who was not involved in the South Carolina case, said for a blood typing problem this serious to happen, “there was some error that was pervasive throughout.”
Vanderbilt University Medical Center in Tennessee and MUSC each accepted offers to transplant the available organs into their patients.
The liver transplant recipient in Tennessee survived the ordeal.
Vanderbilt "complied with all internal and national policies in receiving and transplanting the organ," a spokesman wrote in a statement. He added the medical center treated the incident as a learning process and has willingly taken part in conversations "to do our part in helping improve the process."
The same Columbia law firm is representing both Michelle Holliman and the man who received the liver at Vanderbilt. Lucy Dinkins, an attorney with the firm, said the man in Tennessee had to have a second liver transplant to fix the mistake "and continues to suffer serious complications." No lawsuit has been filed regarding the liver procedure, according to court records.
Michelle first sued We are Sharing Hope SC in July of last year. Her legal team added MUSC and the United Network for Organ Sharing as defendants this spring, and they also filed suit against a surgeon involved in Allen's care this summer.
A spokeswoman for MUSC said the transplant team in Charleston worked off of the blood type information given by the organ network. They wouldn’t learn of the mismatch until Allen's body was rejecting the lungs and fighting to survive.
Reporting gone wrong
Despite a state regulation in place requiring hospitals to report all incidents of death or serious injury in patients within 10 days, no one told the South Carolina health department about Allen Holliman's death, the agency confirmed.
A DHEC spokeswoman said the agency would begin an investigation after the newspaper's inquiry.
MUSC declined to comment on the lawsuit, which is pending. But spokeswoman Heather Woolwine said in a statement the hospital didn’t report Allen’s death to DHEC because “the error occurred outside of MUSC Health processes.”
“Our transplant team cares deeply about its patients and is heartbroken when a patient’s outcome is not successful,” she said. “We can say that MUSC Health providers followed the national standard of care.”
When the federal government got a complaint stemming from the incident in 2019, its investigators found problems with We are Sharing Hope SC's blood-typing policies. There were no standards in place guiding its team on what to do if there was an inconclusive blood test, according to federal reports provided to The Post and Courier.
The Centers for Medicare & Medicaid Services also cited We Are Sharing Hope SC for failing to disclose the error at Vanderbilt. The organization's director of quality told investigators she forgot to make the report. The federal health authority didn’t get a complaint about Holliman's death.
After a complaint, the Centers for Medicare & Medicaid Services disciplined Vanderbilt University Medical Center after a liver with a mismatch…
After a complaint, the Centers for Medicare & Medicaid Services disciplined We Are Sharing Hope SC, the only organ procurement and donation bu…
The hospitals did tell the United Network for Organ Sharing, the national organization that helps match donors and recipients.
Two days after the failed transplants, it sent a memo reminding donor coordinators and every transplant hospital in the country not to rely on blood tests taken after a transfusion. And just this summer, a committee issued new guidance after "recent reports" of mistakes. A network spokeswoman said she couldn’t confirm whether those actions and the South Carolina case were linked.
But she did say “instances of unintended, mismatched blood type transplants are very rare.”
The federal Medicare agency explained responsibility is shared throughout the organ donation process. Two people should confirm the donor’s information at the regional network. And when the organs arrive at the hospital, the surgeon and another staff member should verify blood types.
Ultimately, the surgeon who puts the donated organ into the patient's body is responsible for making sure his or her patient is matched correctly, a spokesman for the agency said.
We Are Sharing Hope SC resolved its issues with the government last year. It, too, declined to comment on the details of Allen Holliman's case.
“We Are Sharing Hope SC follows the standard of care related to the organ donation practice and we take seriously our responsibility to honor the donation legacy,” a spokeswoman said in a statement. “Our sympathies remain with all families who experience the loss of a loved one.”
Death at Duke
Courts are filled with medical malpractice lawsuits, stories of scalpels slicing off the mark, patients’ complaints ignored and even tools sewn into people’s bodies by accident. But with an ultimate gift from a lost life on the line, and another dependent on the organ, little room is left for mistakes.
Jesica Santillan captured national attention in 2003 when her family smuggled her over the border from Mexico, where she lacked the medical care needed to treat her fatal heart disease. Santillan landed at Duke University.
Her surgeon, Dr. James Jaggers, accepted an offer for a set of heart and lungs for Santillan. But there was a miscommunication between Jaggers and the donor coordinator, according to a U.S. News and World Report article. The blood types didn’t match.
Jaggers didn’t discover the problem until the organs were inside his patient. The teenager died after the medical team tried to retransplant another set of the right type.
Major news outlets around the country picked up the story. Duke promised to make its process safer. “Human errors and an insufficient backup system” contributed to her death, leaders said.
Later, Jaggers would say as her surgeon, “I am ultimately responsible for the team and for this error.”
The Joint Commission, a governing body that tracks hospital quality, released its Universal Protocol not long after, aimed at making all surgeries safer. Before a surgery begins, the team should do a “time-out,” the protocol states.
Everyone is supposed to take a beat. The Joint Commission says the surgical team should verify they have the correct patient and are about to do the right procedure. Though the protocol isn’t specific to transplants, these nationally recognized standards suggest labeled lab results be displayed in the room.
If a safety problem kills a patient, the Joint Commission strongly encourages the hospital to report the event. Doing so invites an investigation involving commission experts in the hope of keeping the mistake from being repeated.
One kind of incident the commission wants hospitals to report: Incorrect blood typing.
Contacted by The Post and Courier, the Joint Commission said it was not aware of Allen Holliman’s death at MUSC. But as a result of the newspaper's inquiry, it said it would start a review. The hospital said it didn’t need to make the report, because they maintain it wasn’t their mistake.
Almost 24 hours after Allen Holliman's transplant began, it was clear to his wife something was wrong. He was in critical care.
Michelle Holliman fell into a brief sleep on the couch in the hospital waiting room. She awoke to someone shaking her and a surgeon's pale face as he delivered bad news.
“The answer I got was unbelievable,” Michelle said. “I’m still numb.”
The medical team apologized, Michelle said. Still, she is angry. She feels she doesn’t have the answers she needs, and she knows her husband deserved better.
Nancy Berlinger, a scholar at The Hastings Center, a bioethics think tank in New York, said it should be acknowledged that medicine is never delivered by just one person.
"Safety is created every day by how people work together," Berlinger said.
When a system breaks down, she also said it is important that everyone involved not only apologize, but take responsibility.
Meanwhile, the number of people choosing to become organ donors is on the rise, and Whitson, the Ohio State surgeon, said he wants it to stay that way. People shouldn’t use rare cases of fatal mistakes as an excuse to distrust the process, he said, which “is very robust.”
In South Carolina, if trends hold true, We are Sharing Hope SC will recover organs from more than 100 people this year.