Introduction: Despite an established infrastructure for eye and tissue donation in the UK, referral rates from hospital and hospice settings remain disproportionately low compared to eligibility. An estimated 46% of hospice deaths meet criteria for eye donation, yet referral rates remain under 4%. Public support for eye donation is high, and bereaved families increasingly express a desire for tissue donation to be offered as part of dignified end-of-life care. However, healthcare professionals often avoid the topic due to low confidence, lack of education, and emotional discomfort. In response to a missed referral that deeply affected both family and staff, we launched the NURTURE (Novel Undertaking for Raising Tissue Utilisation and Recognition at End-of-life) project. NURTURE aimed to identify systemic barriers and enable targeted, sustainable improvements in the tissue referral process.
Method: We conducted a retrospective audit of 2,815 deceased patients across 46 wards within three NHS Trusts, examining National Referral Centre (NRC) data, medical records, and organ donor registration status. We developed a ward-level heatmap to identify areas with the highest discrepancy between potential and actual referrals. Eight high-miss-potential wards were selected for further study. A qualitative staff questionnaire was co-designed with hospital practitioners and distributed to clinicians and nurses in the selected wards. Responses were coded thematically to identify knowledge gaps, practical barriers, and cultural or emotional considerations. Interventions were designed using Plan-Do-Study-Act (PDSA) methodology, including targeted education, stakeholder engagement, and proposals for a user-centered digital AI platform.
Results: Of the 1,488 patients qualifying for referral for Tissue Donation, 408 were registered organ donors. 

The data showed a mismatch between high-mortality wards and those with high donation potential. The eight selected wards accounted for 49.2% of missed referrals. Staff responses revealed key barriers: fear of upsetting families (67%), uncertainty about eligibility (59%), time constraints (45%), and lack of feedback or closure after a referral. 

Staff requested clearer guidance, examples of sensitive language, and embedded prompts within electronic systems. Preliminary intervention results indicate increased staff engagement and willingness to discuss tissue donation. An AI tool prototype is currently in planning phase, designed to align with NRC workflows and reduce pressure on frontline teams.

Conclusion: NURTURE illustrates how localized data analysis, combined with front-line engagement and iterative systems change, can identify and address key barriers to tissue donation. By focusing on high-impact areas and staff-identified needs, the project enhances dignity at end-of-life and unlocks underutilized donor potential. This scalable model may inform broader policy and digital development within NHSBT and other donation systems globally.