A transplant patient died after a surgeon failed to disclose he had spilt stomach contents on organs which went on to be used in NHS operations.
The 36-year-old died of an aneurysm caused directly by infection from a donated liver, while two other patients became ill from transplants.
The incident took place in 2015 but only came to light when one of the sick patients attended a hospital in Wales.
It had involved a surgeon from Oxford University NHS Foundation Trust.
The trust has agreed damages of £215,000 for one of the cases.
Several organs became infected with Candida albicans, a fungal infection, after the surgeon cut the stomach in a donor while retrieving organs, spilling the contents over other organs.
The surgeon did not tell anyone as he should have done and the organs were transplanted into three patients.
One recipient died after receiving an infected liver, while a 44-year-old received a kidney and pancreas and a 25-year-old parent from Wales received a kidney.
The incident only came to light after surgeons at Cardiff & Vale University Health Board raised the alarm with the Human Tissue Authority and the Welsh Government.
They became worried when the 25-year-old patient who received the kidney, and who was under their care at the University Hospital of Wales, became seriously unwell due to the infected organ.
The patient, who does not wish to be named but is from south Wales, needed the donor kidney removing as an emergency after suffering extreme pain and extensive internal bleeding.
The 25-year-old was placed in an induced coma and given 16 blood transfusions, before spending a year on dialysis having never needed it before.
Risk of infection
The Oxford University trust has paid £215,000 in damages to the patient after they launched a legal challenge.
A serious incident report by NHS Blood and Transplant (NHSBT) said the surgeon had "no recollection of anything of note" when taking the organs, but had noticed a "small nick" on reflection which saw a small amount of stomach content spilt.
The spill was not documented at the time of the procedure, meaning those receiving the organs and their doctors were unaware of the risk of infection.
The NHSBT report concluded: "This incident represents an example of donor-transmitted infection with Candida albicans which contributed to the loss of one kidney graft and the death of a liver recipient.
"The infection of the graft may have arisen during the retrieval procedure."
The trust admitted it had been in breach of duty of care by the failure of the surgeon to record the cut into the donor's stomach.
'The surgeon wasn't honest'
In defence of the legal action, trust lawyers claimed that, despite the stomach spill, even if known at the time of transplant, the risk would have been considered low.
But solicitor Jodi Newton, a medical negligence specialist at Hudgell Solicitors, representing the patient, said it was "a completely unacceptable breach of duty of care" which was "extremely damaging for patient trust in surgeons".
The patient said: "What angers me to this day is that fact that the surgeon who removed the organs from the donor wasn't honest.
"It was only when people who received the organs became unwell that the truth was told."
Prof Meghana Pandit, chief medical officer at Oxford University Hospitals NHS Foundation Trust, said: "This is a very unusual circumstance and we are keen to ensure that we do everything we can to make sure it doesn't happen again in future."
John Forsythe, medical director for organ donation and transplantation at NHSBT, said: "Our thoughts are with the recipients and their families over this sad and unusual case.
"We acted quickly to investigate what happened and we worked with transplant centres afterwards. Our report concluded the infection of the transplanted organ may have arisen during the retrieval procedure."
It is unclear whether the families of the 36-year-old who died or the 44-year-old are aware of the incident.
NHSBT said it was up to local transplant centres to inform patients about contamination.
Cardiff and Vale University Health Board said the NHSBT investigation which took place after it reported the issue "did not identify any faults or concerns with procedures in Cardiff".