10 November 2022: Manas - A

Professor Manas came to the Inquiry with only a morning slot. This undoubtably meant his role was as an expert who can inform the Chair to form his Recommendations on a specific topic. It was noted that this was another God-believing medic, being a transplant surgeon who has led on the establishment of “super-regional” transplant programmes. He also set up the Institute of Transplantation and was happy to acknowledge how it was focused on the betterment of patients. He is currently the NHS BT medical director or organ and tissue donation. He has been involved in a range of committees and advisory groups that look at patient pathways, responding to the shifting of scientific developments, maximising the benefits of new research, and much more. He noted how there were a lot of problems during Covid with staff going down and leaving transplant services in need of coverage from outwith their cohort of personnel.

Counsel mentioned the focus of the questions to the witnesses’ being related to the National Liver Offering Scheme. That body is made up of clinicians, patient representatives and others. There is a Liver Advisory Group, but there is no representation of people from the infected blood community. Their possible involvement has never been discussed, and there was also the fact of the numbers of patients is going down due to the success of the Direct Acting Antiviral (DAA) treatments.

A big issue for liver transplantation is the number of donors and the judgements over who could be prioritised to receive a liver. There was no standard way of deciding who was prioritised for transplant. Criteria was set based on the concept of a patient having a 50% chance of survival five years after transplant. This has become adopted across the world. A scoring system was developed to make the calculation possible. It was noted that even having a liver transplant is a factor since some people would be better off not having a transplant because it is such a major surgical procedure with many complications. Policies for deciding who receives a liver cover issues such as equity, utility, and benefit.

Organ donation and transplantations started in 1954. It involved defining a donor as “brain dead” to allow the liver to be in the best condition as possible when removed. There were many ethical issues, including the decision of when to stop the treatment to a dying donor, which results in “circulatory death”. When someone dies in this way, there has to be a five to ten minute wait to ensure there is no possibility of recovery. In that waiting window parts of the body starts to shut down. This impacts on how useful a donated organ will be. Brain-dead patient livers last longer so can be transported further from the site of the death of the donor to the hospital where the recipient might be.

There was a review of the decision-making process. It involves criteria such as “super urgent” patients who have no more than 48 hours to live. All clinical decisions have to be taken quickly and this is assisted by the decision-making schema and robust back-up processes to ensure information flows easily and the best outcome chances are achieved. There are seven donor characteristics and 21 recipient characteristics. Some recipients need a near perfect match to be successful. Some types of transplants are only carried out at a small number of locations. The “design” of the liver allows it to be split left and right in some cases. All this effort has increased the number of transplants and the success of these in sustaining longer and better quality of life. Prior to the new DAA treatments, having HCV was a negative factor in the expected outcome of transplant. Nowadays it would be normal for a recipient to have already achieved a sustained viral response due to the new treatments prior to transplant.

HBV is not seen often compared to HCV. HBV does not normally cause much liver damage, whereas HCV infected patients have a 90% chance of suffering a damaged liver. HIV is seen as a co-morbidity in the consideration of transplantation. Liver transplants are a risky operation. Each liver has to be assessed to ensure it is suitable for a possible recipient since every liver is unique. “Transplant benefit scores” are computed using the seven donor criteria and the 21 recipient criteria. One factor is the chance of survival of the liver (“M2”) and there is also a factor related to the receiving patient (“M1”). But patients did not want a computer to decide who does and does not receive a liver for transplant, so it involves a clinician using the computer-generated score to advise them. This helps to avoid any clinician making a decision which is arbitrary or favours one patient over another for non-clinical reasons.

Prof Manas comes across as a highly skilled and fully informed expert witness. He seems very comfortable in describing processes he was key in developing, including the rationale for why things are done the way they are. He is occasionally reflective or willing to pass comment as an informative aside. There is no pretence that it is a perfect process he helped to design, but there is an underlying confidence that it is as good as it can be. Some things are a given, such as the time constraints on how long a liver can be kept cold and starved of oxygen before it becomes unusable. Some things are down to the interpretation and judgement of clinicians, which is greatly assisted by the processes, but still has capacity to rely on a human being. “If you feel in your heart of hearts”, said the witness tellingly about the moment of decision-making, including whether to recommend to a patient that donating or receiving is in their best interests. At these moments patients are often confused, worried, and not in a good place to make logical decisions.

In some places an “elderly” donor is 60, but in the UK an elderly donor is 75. Increasingly, donors are older people. This means they may have more fatty livers, or other factors affecting the quality and useability of their liver. At end of life care, once the machines are “switched off”, organs such as the liver suffer after blood pressure goes below 50. Monitoring of transplant recipients noted that the process seemed to favour older people, which was discovered to be a statistical anomaly and was corrected for in the process going forward. When a liver is offered to a patient but is not accepted by the hospital, for example, due to lack of staff or a theatre not being available, that patient has to be told under the concept of there being a duty of candour.

Counsel explored how it might be possible to add greater emphasis to the criteria for patients who have a transplant need due to something related to infected blood. The witness discussed how that might be possible but seemed confident that the system may already be the best design for them. He spoke about how bad the previous anti-viral “nightmare” treatments were, and the whole history of contaminated blood. However, the focus for the process is not about the historical context but has to be based on the health of the liver now.