Maisie Almond

I am Adrian Farrow, assistant coroner, for the coroner area of Greater Manchester South

An   investigation  was  commenced   into  the   death  of   Maisie  Kate  Almond.  The investigation concluded at the end of the inquest on 26 th February 2026. The conclusion of the inquest was that Maisie died on 2 nd October 2024 at Leeds General Infirmary, Leeds. She developed acute liver failure which first manifested itself on 15 th September 2024 for which no underlying cause could be found despite exhaustive investigations both  at  Tameside  General  Hospital  and  the  specialist  Liver  Centre  in  Leeds.  She developed consequential swelling to her brain and damage to other internal organs which brought about her death whilst awaiting urgent liver transplant surgery. I concluded that she had died from the effects of a rare form of acute liver failure before a suitable donor liver could be found for priority transplantation.

Maisie was 14 years old. She was fit and healthy with no history of any underlying health issues. She became ill on 15 th September 2024 and was admitted to Tameside General Hospital on 16 th September 2024 and was diagnosed with hepatitis. Investigations were undertaken over the course of the following 10 days, with three separate admissions to hospital with worsening condition. The investigations ruled out any identifiable infections, genetic or other causes the acute failure of her liver. Throughout this process, the hospital worked with the advice of the northern Liver Centre based at Leeds General Hospital. On 26 th September 2024, Maisie was transferred to the Liver Centre in Leeds and on 27 th September 2024, she was listed for liver transplant. A suitable donor liver did not become available until 1 st October 2024, but which time, Maisie had sustained cerebral oedema and other organ damage which made the prospects of her survival so low that the transplant did not take place and Maisie died on 2 nd October 2024. The medical cause of her death was: 1a) Cerebral oedema and multi-organ failure;  1b) Seronegative acute liver failure.

During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the  circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. During the inquest, I heard evidence from a consultant paediatric hepatologist that there is a national shortage of donor livers generally and particularly for children in the “super urgent” category. The clinical guidance not to utilise cardiac death donor livers in such cases due to the poor historical outcomes has narrowed the pool of suitable donor livers to those arising from brain deaths. Altruistic living liver donations are generally not available for super urgent cases. The evidence I received was that the number of donor livers has reduced by a third and the effect is that whereas, historically, a donor liver could be expected to be made available within 48 hours, the wait has now extended to up to a week. That delay gives rise to a clear risk that lives will be lost due to the unavailability of suitable donor organs.

In my opinion action should be taken to prevent future deaths and I believe you and your organisations have the power to take such action.