'Perfect storm' of events led to transplant fiasco -- watchdog
A seriously ill teenager missed her chance of a vital liver transplant because of a "perfect storm of events" involving several agencies.
A health watchdog report into the circumstances in which 14-year-old Meadhbh McGivern was unable to receive her transplant at King's College Hospital in London in July found no one person or agency was in charge of her care or transportation.
But it failed to identify any individuals involved in the debacle.
As the teenager continued her agonising wait for a transplant last night, unsure if another donor would become available soon, her father Joe said he feared the same thing could happen to another child.
Meadhbh, from Ballinamore, Co Leitrim, did not get to London in time for her transplant on July 2 after the authorities failed to organise a flight until it was too late.
She has spent two years on a waiting list -- the longest a paediatric patient has ever waited for a transplant in this country.
It emerged that several agencies were involved in a "desperate and frantic" attempt to secure transport on the night of July 2 -- the HSE, the Coast Guard, the Department of Transport, the Air Corps and the Emergency Medical Support Services (EMSS).
The teenager was minutes from boarding a Coast Guard helicopter at Strandhill airport in Co Sligo and ending her two-year wait when she was informed she would not make it to London before a 2am deadline. Meadhbh's organ was given to another recipient.
The family had been informed by the London hospital that the transplant would need to take place quickly because the donation liver belonged to a "non-breathing" donor. However, this vital information was not communicated to those in charge of her transportation.
Later, a mistaken assumption made by personnel in the ambulance service and Crumlin Hospital that a coast guard helicopter would get the teenager to London in 90 minutes led to a decision to cancel a private jet sourced by Crumlin.
It later transpired the flight and subsequent journey to the hospital would take four hours by helicopter. Crucially, the report also found an Air Corps executive jet landed in Baldonnel airport at 10.30pm that night, which could easily have transported the teenager on time.
However, after being told an aircraft was not available earlier in the evening, nobody involved in Meadhbh's transportation called the Air Corps back to check if another aircraft had subsequently become available.
Mr McGivern said last night: "The one thing that has been sidelined for one reason or another is that the Air Corps was available on the night. I am not convinced that the agencies involved were unaware that this aircraft was available."
A series of interim measures have now been put in place before the setting up of a national centre to co-ordinate the transfer of patients by air. However, Mr McGivern says he is not convinced these measures will prevent the same thing from occurring again.
The report revealed how Crumlin Hospital had recently taken over the role of co-ordinating the transportation of children going from home to King's College Hospital when state aircraft are not available.
However, this was done, it states, "without the required competencies and skills to effectively undertake that function or to understand the associated risks. What competencies and skills have these people developed since?" asked Mr McGivern.
"Until these recommendations are implemented I can't see how this would not happen again,"he added.
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 Meadhbh 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 Meadhbh'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 added.
He said the availability of state-owned aircraft to bring Ms McGivern for surgery had been "significantly diminished".
He also said key pieces of information had not been provided on the night and that this had lead to the difficulty in arranging transportation.
The most crucial piece of information that was not passed on was that the type of liver being offered -- from a non-heart-beating donor -- meant that the deadline for surgery was shorter than usual.
One of the directors of the private transportation company EMSS, Declan Traynor, said he was "happy with the outcome and the recommendations laid down in the report and the "timely manner in which it was prepared".
Mr McGivern said the report's findings had confirmed what he and his wife had suspected all along -- that there "was never a plan in place".
"The findings are frightening," he added.
"Had we stayed quiet on this nobody would ever have known of the lack of plans and protocols. Somebody could have died because of it."