Family members of two transplant patients who died after being given donor kidneys infected with parasitic worms have urged the implementation of a coroner's recommendations.
Robert Stuart (67) and Darren Hughes (42) died days apart after each being given an organ from the same alcoholic who died of suspected meningitis.
Tests on their bodies later uncovered the presence of an ultra-rare parasite usually found in horses. There have only ever been five cases in humans, all fatal.
The man presiding over the inquest into the deaths of the two men concluded the surgeon who carried out the transplant could not be blamed for what was described as a tragic and freakish set of circumstances.
However, three months on from the hearing and acting coroner Christopher Woolley published a report saying there were still issues that should be addressed.
Among his recommendations were that Cardiff and Vale University Health Board change the way it accepts organs - doing it on a "team" basis rather than a consultant having the final say. Mr Woolley also said the consent forms should be redesigned.