Teen liver transplant fiasco: HSE and hospital to blame
An inquiry into the failure to get 14-year-old Meadhbh McGivern to London for a liver transplant earlier this summer has found no authority was in charge.
The Health Information and Quality Authority also found there was no evidence that Our Lady’s Children’s Hospital Crumlin, the HSE or the National Ambulance Service understood or managed the risks of care.
There was also confusion between the hospital and the ambulance service in relation to who was responsible for transfer and transport logistics.
Dr Tracey Cooper, Chief Executive of HIQA, said: "The night of 2 July 2011 resulted in a devastating outcome for Meadhbh - a failed transportation for a liver transplant. 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. However, this was in the absence of any organised or managed system, or the required knowledge of logistics to adequately do so."
Ms McGivern from Ballinamore, Co Leitrim was about to board a Coast Guard helicopter in Sligo when she and her parents, Joe and Assumpta, were told they would not make it to King’s College Hospital London before a 2am deadline.
The family had also been told the operation would have to take place quickly because the new liver belonged to a “non-breathing” donor.
But four hours had lapsed since the McGivern family had been offered the life-changing transplant.
Health Minister Dr James Reilly, who called for the HIQA inquiry, said Government departments of health, transport and defence have been tasked with setting up the new 24-hour co-ordination unit along with the Health Service Executive (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.
Dr Reilly said the missed transplant should not happen again and welcomed plans for the new National Aeromedical Co-ordination Group.
"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.
HIQA warned that it had uncovered an over-the-top focus on the cost of getting a patient to London and who was going to pay.
"The overly administrative focus on the funding and reimbursement of travel and transport diverted attention from the safe and timely transfer of care for patients," the report said.
The McGiverns were alerted by King's Hospital staff at 7.20pm on Saturday that a potential non-heart-beating liver was available.
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).
A catalogue of calls between several agencies and the family appeared to show a breakdown in communications among the teams involved.
The HIQA inquiry found each agency relied on "individual experience of people involved in a process that was inherently risky and logistically challenging because of its complexity and the consequences for children if it went wrong".
The watchdog said that although the system had worked in the past, it was not designed to be reliable.
It highlighted a lack of overall co-ordination of the communication, logistics and deployment of "air ambulance" resources.
Dr Cooper added: "It is imperative that we learn from Meadhbh's experience and take the actions we need to as a State in order to reduce the likelihood of such an incident from occurring again. All of the agencies involved on the night have already made changes to improve the process."
HIQA uncovered three key pieces of information not properly shared among agencies on the night:
:: The type of non-heart-beating donor liver being offered meant that the deadline for surgery was shorter than usual;
:: The latest time Meadhbh was required to arrive at King's;
:: The ETA of the Coast Guard helicopter in London as soon as it was selected as the available and viable air ambulance transport.
Hiqa found a number of factors exacerbated the failures, including a lack of knowledge about the transport of patients by air and precise timelines involved and no checking or re-checking to see if a state jet had been cleared for the flight.
The Air Corps, Coast Guard and other service providers have been asked to support the new 24-hour co-ordination unit.
The HSE has been given one month to develop a plan to meet the 14 recommendations in the report.