Donation and Transplantation Plan 2021 to 2026: annual progress update - December 2025

6. Priority 3 - Reducing missed opportunities for deceased donation

6.1 Ensure use of Specialist Requesters to approach families about organ donation in all donating hospitals to help improve authorisation and reduce overrides where the patient was on the NHS Organ Donor Register (ODR).

Reducing missed opportunities for organ donation remains a national priority, particularly as the eligible donor pool continues to decline. As outlined last year, fewer people are dying in the right circumstances to facilitate donation making consistent high-quality family approaches essential to maximising donation activity.

The Specialist Requester (SR) model remains well embedded and successful in Scotland, with SRs mobilising across all regions to support sensitive, well-structured donation conversations. Their role continues to be pivotal in improving authorisation and reducing overrides where the patient is registered on the NHS Organ Donor Register (ODR).

Nationally, approaches are undertaken by both SRs and Specialist Nurses for Organ Donation (SNODs). Last year, 54% of all approaches included an SR, reflecting the shared responsibility for ensuring high-quality conversations with families.

6.1.1 Performance Update April 2025 – October 2025

• The overall authorisation rate in Scotland is 63%, a decrease from 67% during the same period last year.
• Donation after Brain Death (DBD) authorisation remains high at 88%, while Donation after Circulatory Death (DCD) authorisation is 55%.
• Specialist nurse presence during family conversations has reduced to 88% (from 91% last year).
• Expressed opt-in authorisation stands at 83%, still the highest in the UK, although down from 89% last year.
• A key factor affecting the balance between DBD and DCD outcomes is the reduction in Neurological Death Testing (NDT), currently at 51%, the lowest year to date in the UK. This is likely artificially elevating DBD consent figures while lowering DCD consent, as some potential DBD donors are being categorised as DCD when families decline donation before NDT is carried out.

6.1.2 Importance of Specialist Requester deployment in all donating hospitals

• In the current context of reduced NDT utilisation and variable specialist nurse presence, consistent deployment of Specialist Requesters (SRs) is increasingly important. SRs provide:
  • Improved authorisation rates
  • Consistent delivery of shared decision-making
  • Enhanced family reassurance and understanding
  • Reduced overrides of the NHS Organ Donor Register
  • Better early engagement and parallel planning with clinical teams
  • While SNODs and SRs continue to work collaboratively to minimise missed opportunities, expanding the use of SRs across all donating hospitals presents a clear opportunity to stabilise and improve authorisation performance.

Despite strong performance in several areas—including leading UK expressed opt-in authorisation—Scotland is experiencing a decline in overall authorisation, reduced NDT testing and lower specialist nurse presence. Strengthening the existing model through consistent SR involvement in all approaches will support families, reduce missed opportunities and help improve authorisation outcomes.

6.2 Monitor and review use of Specialist Requester model

Following the introduction of the Specialist Requester (SR) model in January 2020, an evaluation was undertaken three years later in June 2023. This concluded the SR model was effective, with the improvement of authorisation rates, rota sustainability and reduction of 24-hour working.

A further recommendation from this evaluation concluded that the specific monitoring of authorisation rates due to the SR model cannot be accurately measured due to many variables in the data collection.

However, the continued monitoring of combined authorisation rates of specialist nurses and SRs will ensure that the benefits of a flexible SR model can be assured.

6.3 Via opt out implementation and longer term, increase awareness raising among NHS staff about referring potential tissue donors

SNBTS has continued to work to minimise missed opportunities for tissue donation across hospitals and hospices by raising awareness and providing teaching and training to NHS staff around the importance of considering the potential of tissue donation for all deaths. For example, their work has included:

• Supporting Organ and Tissue Donation Week with specific focus on eye donation storylines and supporting the Scottish Parliament exhibition.
• An increasing number of face-to-face education awareness sessions have been held in territorial boards.
• Supporting three clinical improvement programmes in hospitals focussing on improving tissue donor referrals.

SNBTS has also been working to embed the referral of potential multi-tissue and eye donors as a routine part of standard end of life care in hospitals, hospices and with Organ and Tissue Donation Committees.

SNBTS has also been monitoring tissue referral rates and the reasons for tissue donation not being authorised, considering if there are any further steps which could be taken to increase donation. The overall potential multi-tissue donor referral rates have almost returned to pre-pandemic levels, however, SNBTS has identified that the type of donor being referred appears to have changed since the coronavirus (COVID-19) pandemic with a significant number of all referrals now having complex medical histories and also evidence of higher risk behaviour, leading to a high deferral rate. Indeed 62-75% of all referrals received are identified as not being suitable for tissue donation.

SNBTS’s data also demonstrates a worrying trend for a year-on-year increase in the rate of family declines with a relative increase of 37% in the family decline rate between 2022 and 2024. SNBTS are aware that this trend is replicated UK wide. NHS Blood and Transplant reported a 41% family decline rate across the UK and the Scotland Specialist Nurse Organ Donation team reported a 36% refusal rate in 2024. Work is ongoing nationally to identify reasons for this and how we can collectively reduce decline rates.

6.4 Ensure a robust eye retrieval service for Scotland is in place and continue to monitor and review progress on increasing eye donation.

SNBTS has been actively monitoring progress with the aim of ultimately achieving sufficient eye donors in Scotland to meet the clinical demand for cornea transplants for patients in Scotland.

Following the ending of an arrangement in September 2024 between SNBTS and NHS Blood and Transplant to fund eye retrievers, SNBTS have agreed to continue to provide a limited eye retrieval service based on cost recovery.

SNBTS has also been working with the Scottish Government to develop a more robust plan to maintain and improve an eye retrieval service in Scotland and in 2024/25, the Scottish Government provided baselined and recurring funding of just over £260,000 for an additional four retrieval staff and two Tissue Donor Coordinators to expand eye donation rates in hospices, hospital palliative care units and our traditional referring centres. The Minister for Public Health and Women’s Health attended SNBTS to discuss these plans and promote eye donation on 2 December 2025.

In the current financial year April – November 2025:

• 140 corneas and six sclera were transplanted in Scotland. This remains lower than pre-pandemic levels.
• The SNBTS retrieval team have retrieved 54 eyes from 27 donors which is unchanged since this time last year.
• There is currently a UK-wide national shortage of eye tissue for transplant.

In order to further increase the donation rate, SNBTS is working with hospices to enable some of those who die to also have the opportunity to donate their eyes. One hospice has been onboarded and four further hospices are set to begin an eye donation programme in the near to middle future.

There is however evidence from potential donor audits carried out in the hospitals in the central belt of significant numbers of potential eye-only donors not being approached by clinical staff about the potential for donation. The reason for this is multi-factorial – partly due to the complexity of the process followed for referral of eye-only donors and partly because retrieval resource has only been available during normal working hours. The additional resource provided by the Scottish Government will address both of these challenges by streamlining the approach and authorisation by the Scottish tissue donation nurses and ensuring the availability of staff for seven day a week retrieval.