The report into the circumstances in which a girl (14) was unable to receive a liver transplant in London has found that no one person nor agency was in charge of her care or transportation.
Maedhbh McGivern from Ballinamore, Co Leitrim, lost an opportunity for a liver transplant at King’s College Hospital in London on July 2nd after the authorities failed to organise a flight until it was too late.
Several agencies were involved in trying to secure transport - the HSE, the Coast Guard, Department of Transport, the Air Corps and the Emergency Medical Support Services (EMSS).
The by the Health Information and Quality Authority (Hiqa) recommends the establishment of a new 24-hour National Aeromedical Co-ordination Group to prevent a repetition.
Ms McGivern, who is still awaiting a donor, was about to board a Coast Guard helicopter at Strandhill airport in Co Sligo when she and her parents, Joe and Assumpta, were informed they would not make it to London before a 2am deadline. The family had been informed by the hospital the transplant would need to take place quickly because the donation liver belonged to a “non-breathing” donor.
Today, Hiqa chief executive Dr Tracey Cooper said there had been a “perfect storm of events” on the night in question last July. “It was clear from the findings of our inquiry that the people involved in attempting to get Maedhbh to London entered into desperate means to try to do so,” Dr Cooper said. “However, this was in the absence of any organised or managed system, or the required knowledge of logistics to adequately do so.
“The overriding finding that contributed to Maedhbh’s failed transportation was that no one person or agency was in charge or accountable for the overall process of care and transportation for Meadhbh.”
Dr Cooper said the availability of State-owned aircraft to bring Ms McGivern for surgery had been “significantly diminished”. She also said key pieces of information had not been provided on the night that lead to the difficulty in arranging transportation.
These were:
* The type of non-heart-beating donor liver being offered meant that the deadline for surgery was shorter than usual;
* The latest time Maedhbh was required to arrive at King’s Hospital;
* The estimated time of arrival of the Coast Guard helicopter in London as soon as it was selected as the available and viable air ambulance transport.
The Hiqa report found there had been “an absence of knowledge" about the transportation of patients by air and the precise timelines involved.
“Even though there had been successful transport of many children to London for operations in the past, the report found the system was “not designed to be reliable".
It said there was an absence of clear process allowing health authorities to keep checking if State aircraft became available as time passed. It also said there had been ineffective communications and a lack of effective contingency planning. "These factors exacerbated the situation and also contributed to the final outcome," it said.
Dr Cooper said all of the agencies involved on the night have already made changes to improve the process.
Minister for Health James Reilly, who announced an inquiry into the circumstances in July, said the missed transplant should not happen again and welcomed plans for the new National Aeromedical Co-ordination Group.
Dr Reilly said the Government departments of health, transport and defence have been tasked with setting up the unit along with the HSE.
"If we are to prevent the sort of devastating outcome that the McGivern family underwent, we need a clear and robust process for the organisation and supply of timely and appropriate transport when donated organs become available," Dr Reilly said.
“I am confident that it will produce an effective and pragmatic implementation of the report’s recommendations, so that, where Irish patients need life-saving transplants that are not available here, they can be confident that they can take up appropriate offers elsewhere,” he said.
In a joint statement, the HSE and Our Lady's Children's Hospital, Crumlin, which had helped to co-ordinate the failed transfer, said they sincerely sympathise with the McGivern family and are mindful of the distress caused.
Robert Morton, director of the HSE National Ambulance Service, said all patients awaiting have since been given individual transport plans.
"This is the first time in our experience that an urgent transfer like this has failed, and we have sincerely apologised to the family for the distress caused, and share their ongoing concern for Meadhbh's health," he said. "We will work to ensure that the whole patient transfer system learns from this incident and that we strengthen the service arrangements in line with the investigations carried out."
As part of a new air ambulance regime the Air Corps and Coast Guard will provide twice daily updates at 9am and 5pm to the National Ambulance Service on the availability of aircraft. It will also warn the service when an aircraft is on another mission or out of action.
Irish Patients' Association chairman Stephen McMahon said the creation of the new centre "creates an opportunity to better co-ordinate air medical transfers from remote areas".
"We trust that financial considerations will not delay the implementation of the recommendations," he said.