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From 2015-2018, the Norwegian Board of Health Supervision carried out supervision of donor hospitals and the transplantation centre, where donation of organs from donors and transplantation are carried out.

We found that systematic management of organ donation and/or transplantation had been carried out to varying degrees by the management of the health trusts. Supervision clearly indicated that most doctors and nurses responsible for donation, personnel responsible for co-ordination of transplantation, and other involved personnel, took responsibility for their tasks. We found that some personnel took responsibility for organ donation, although their health trust had inadequate guidelines or lack of guidelines.

Organ donation and transplantation shall not be carried out without clear guidelines, and shall not be dependent on individuals. Leadership and management of donation and transplantation was so inadequate in four of the health trusts that we concluded that this represented breaches of the statutory requirements.

In these four health trusts we identified inadequacies of leadership and management in the following areas:

  • Planning and organizing
  • Developing routines and guidelines for organizing the activities of donor hospitals and/or the transplantation centre
  • A description of tasks, responsibilities and authority for nurses, doctors and other personnel
  • Following up and documenting the qualifications and training of personnel
  • Monitoring the activities of the donor hospitals regularly and systematically.