The Health Information and Quality Authority has published its report into the circumstances that led to the failed transportation of Meadhbh McGivern for transplant surgery on 2 July 2011.

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 organisedor 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.”

The Authority established that there were three key pieces of information that were not provided on the night, these were:

• the fact that the type of donor liver being offered meant that the timeframe from the organ being available to transplantation was shorter than usual
• the required arrival time for Meadhbh to get to King’s College Hospital, London for viable transplant surgery
• the provision of the earliest estimated time of arrival for the Sligo Irish Coast Guard helicopter to land in London at the point at which the Sligo helicopter was deemed to be a viable means of transportation.

The absence of this information resulted in a series of critical decisions being made during the process that contributed to the failed transportation of Meadhbh to King’s College Hospital. 

Furthermore, the Authority also found that there was an absence of knowledge about the transport of patients by air and the precise timelines involved, an absence of clear processes with re-visit protocols to check if State aircraft had become available as time passed, ineffective and multiple communications and a lack of effective contingency planning. These factors exacerbated the situation and also contributed to the final outcome.

In relation to the process, there was no evidence that checklists were developed or used for minimising error. Each organisation relied on the individual experience of the 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. Consequently, although many children had had successful transportation to London for the purpose of transplant surgery in the past, up until the night of 2 July, the system was not designed to be reliable.

“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,” Dr Cooper said, “all of the agencies involved on the night have already made changes to improve the process”.

During the course of the Inquiry, the Authority also identified that there was a lack of overall coordination of the communication, logistics and deployment of ‘air ambulance’ resources in meeting the needs of the full range of patients who may require such assistance.

The Authority makes 17 national recommendations which address the improvements identified from the review of the circumstances that led to the failed transportation of Meadhbh McGivern on 2 July, and also identify actions that need to be put in place to coordinate an optimum aeromedical service for Ireland.

These recommendations will require the three main State agencies – the HSE, Air Corps and Irish Coast Guard; Our Lady’s Children’s Hospital Crumlin, King’s College Hospital and other relevant service providers; and the Departments of Health, Defence and Transport, to continue to work in collaboration and provide the necessary commitment and leadership to bring about the changes required.

One of the key recommendations of the report is the establishment of a National Aeromedical Coordination Centre, within the HSE National Ambulance Service, which will coordinate all of the transport of patients by air and will be the single point of accountability for this process. It will be provided by people trained in the required skills and competencies in aeromedical logistics 24 hours a day. This will be established with the support and assistance of the Air Corps, Irish Coast Guard and other service providers.

The HSE is required to work with the relevant agencies to coordinate an overall national implementation plan for the recommendations within one month, with regular progress reports to be provided to the Minister for Health, the Authority and also made publicly available.

Dr Cooper thanked Meadhbh and the McGiverns for their time and input into the Inquiry, the other families who came forward to share their experience with the Authority and all of the agencies involved in the Inquiry – all of which cooperated fully with the Authority in order to identify and bring about the required improvements.

The report has been submitted to the Minister for Health for his consideration.

Further Information: 

Sinead Whooley, Communications Manager, Health Information and Quality Authority
Tel: 01 8147488/ 087 9221941 Email: swhooley@hiqa.ie

Notes to the Editor: 

• At the request of the Minister for Health, this Inquiry was set up to establish the facts of the events that culminated in the failed transportation for Meadhbh on 2 July 2011, to review the existing inter-agency arrangements in place for people requiring emergency transportation for transplant surgery, and to identify any actions that need to be taken to improve these arrangements.
• MeadhbhMcGivern is 14 years old. Her parents Joe and Assumpta, were told on Saturday 2 July 2011 at 19:20 that a liver was available for transplant in King’s College Hospital, London. Over the subsequent hours, events unfolded in relation to the care and transportation of Meadhbh which culminated in Meadhbh not reaching King’s College Hospital and not receiving a liver transplant.

Key Findings:

• The Authority found that the necessary governance and accountability arrangements were not in place.
• It was evident from mapping the process that there was no single coordinating agency or person with overall accountability.
• There was no overall effective governance of the Treatment Abroad Scheme service model. 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.
• There was no evidence that Our Lady’s Children’s Hospital Crumlin, the Health Service Executive corporately or the National Ambulance Service within the HSE, understood or managed the risks of the model of care or that these risks were recorded on risk registers.
• There was confusion between the Health Service Executive’s National Ambulance Service and Our Lady’s Children’s Hospital Crumlin in relation to who was responsible for transfer and transport logistics 
• There were no mitigating actions or contingency plans in the event of no State plane or helicopter or private air ambulance being available – again, this was mainly due to the fact that no agency had overall accountability for the process.
• Where individual agencies or service providers had their own governance arrangements for their specific part of the process, these were not sufficiently coordinated with other key agencies or providers.
• Of particular concern to the Authority was that Our Lady’s Children’s Hospital Crumlin did not have the required skills and competencies to effectively undertake the role it had recently taken on of coordinating the road and air travel, including aircraft logistics and flight times and the booking of private air ambulances for children going from home to King’s College Hospital.
• Multiple agencies and service providers were all contributors to coordinating a patient’s transfer and transport abroad for organ transplantation. In this case it included King’s College Hospital, London; the HSE National Ambulance Service, Our Lady’s Children’s Hospital Crumlin; the Air Corps, the Irish Coast Guard, the private service provider - Emergency Medical Support Services as the then appointed transport coordinator, and the patient’s family.
• Each organisation involved in this process relied on the individual experience of the people working on it in a process that was inherently risky and logistically challenging because of its complexity and the consequences for patients if it went wrong. Consequently, the system was not designed to be reliable. 

Key Recommendations:

• The HSE should establish a National Aeromedical Coordination Centre within the National Ambulance Service, with the support of the Air Corps and Irish Coast Guard, within the next two months.
• The HSE should establish a National Aeromedical Coordination Group. The Group should be comprised of the main agencies and providers involved in patient transportation by air for transplant surgery and emergency patient episodes, and include a service-user representative.
• The Group should meet within four weeks of the publication of this report and should, as a minimum, meet every two months for the first year, develop, audit and monitor a series of key performance indicators for the provision of air and land logistics for patients.
• The HSE should establish a ‘Live’ information management system which details the availability of each State plane or helicopter at any one point in time with detailed classification information available for the National Aeromedical Coordination Centre regarding the travel times, refuelling requirements, capacities and ranges of each of the State assets and of changes in the status of availability of each.
• The accountability and management of this system should rest with the National Aeromedical Coordination Centre in collaboration with the Air Corps, Irish Coast Guard and any other relevant service provider.
• A checklist should be developed by all the agencies involved in the transfer and transport process to ensure that the possibility of errors at critical points are reduced or prevented. (This should incorporate mandatory information, including the required time of arrival at King’s College Hospital). The implementation of this should be audited for compliance.