A 49-year-old dad passed away within a year of having transplant surgery after he was mistakenly given a cancerous kidney.
Parminder Singh Sidhu had had a kidney transplant, but developed complications when a cancer grew on the kidney.
Despite the enormous unlikelihood of this happening, West London Area Coroner Lydia Brown recorded that a cancerous donor organ is a "recognised but very rare complication".
A scan four months after the transplant revealed a growth on the organ, but at the time it was dismissed as a cyst.
Tragically, it was later found to be an extremely aggressive form of cancer, which then spread from the donor organ.
Sidhu’s widow, Tarjinder, 47, said: “My husband trusted his doctors so much. How did they miss this?”
Lydia Brown, the west London area coroner, said in a narrative conclusion: “This death was due to a recognised but very rare complication of a planned transplant.”
The inquest also heard that there was no reason for the doctors to have concerns about the organ because the donor had no signs or history of cancer.
Frank Dor, consultant transplant surgeon at Imperial College Healthcare NHS Trust, said: “There were no concerns. We were all quite shocked.
"Even in retrospect, we couldn’t find any reason why this transplant shouldn’t have happened.”
Sidhu, from Hounslow in West London, had first developed kidney problems in his 30s, and had previously had a successful transplant in India.
However, the organ had become more troublesome during lockdown and Sidhu, who worked as a DHL airside loader at Heathrow, decided to have the organ removed and replaced.
Medical staff had no reason to suspect that the donor had cancer as she had died of a head injury.
However, by the time they spotted the cancer it had already spread from the donor organ to Sidhu's spine, and despite removing it he passed away in March this year.