Meadhbh’s transplant hopes dashed by lack of agency with sole responsibility
A Health Information and Quality Authority (HIQA) report into the incident claimed there was no evidence of any checklists by any of the agencies involved in making the transport arrangements.
The report states each of the various agencies had relied on the experience of individual staff members in a process that was “inherently risky and logistically challenging”.
“Consequently, the system was not designed to be reliable,” it concluded.
HIQA said six agencies and the McGivern family were involved in trying to make the transport arrangements on July 2 — Our Lady’s Children’s Hospital, Crumlin; the Health Service Executive, the Air Corps, the Irish Coast Guard, King’s College Hospital, London, and the Emergency Medical Support Services.
The report documented and examined 76 phone calls made between the parties over a four-and-a-half hour period.
The report states three key pieces of information were not provided on the night, resulting in a series of critical decisions being made:
* The failure of King’s College Hospital to alert the Emergency Medical Support Services that the available liver was from a “non-heartbeating” donor, which meant the timeframe for the organ being available for transplantation was shorter than normal;
* The failure to notify the various Irish agencies of the required arrival time for Meadhbh to get to the London hospital;
* And the failure to provide the earliest estimated time of arrival for the Irish Coast Guard helicopter, based in Sligo, to travel to London.
The report, which makes 17 recommendations, states it was the first time any child from Ireland had been offered a “non-heartbeating” donor organ, which meant none of the agencies had the experience of making transport arrangements to fly a patient to London within a four-to-six-hour timeframe.
The report reveals there were no contingency plans in place in the event that no aircraft was available from the Air Corps, the Irish Coast Guard or private air ambulance operators.
It found there was confusion between the HSE’s National Ambulance Service and Our Lady’s about their respective roles and responsibilities.
The 76-page report is also critical of what it claims was the “overly administrative focus on the funding and reimbursement travel and transport”. However, HIQA chief executive Tracey Cooper stressed that financial considerations had played no role in the failure of the various agencies.
The report states the decision to tell the McGiverns at around 8pm to stay at their home in Ballinamore, Co Leitrim, was critical. However, it added that such an instruction was normal practice until an aircraft and airport were confirmed.
It emerged that three of the Air Corps’ four fixed-wing aircraft were out of service, while the other aircraft was due to fly back from Nice to transport President Mary McAleese home from the wedding of Prince Albert of Monaco earlier that day.
An Air Corps helicopter was unavailable as it was involved in the transfer of another patient with spinal injuries.
Regardless, the Air Corps said a direct night-time flight to Heathrow is beyond the fuel range of its helicopter fleet.
The Irish Coast Guard’s helicopter in Dublin was unavailable due to technical problems. Its crew were en route to Shannon to pick up a replacement helicopter, but were not scheduled to land back in Dublin until 11pm.
The helicopter based in Sligo was unavailable as it was providing emergency cover for the northern half of the country.
The HIQA report states that the decision taken shortly before 10pm to cancel a private aircraft which had been chartered by Our Lady’s about 15 minutes earlier and to accept the use of the Coast Guard’s helicopter based in Sligo was critical.
It found the decision had been made on the inaccurate assumption that the journey time between Sligo and London for the helicopter was 90 minutes, when, in fact, it was over three-and-a-half hours because of the need to refuel.
In addition, the Air Corps aircraft which had been in Nice became available at 10.30pm in Baldonnel.
The report states the protocol in place says that if a state aircraft was available, it had to be used.
HIQA acknowledged that all the parties involved in making the transport arrangements had made valiant efforts to find an aircraft.
However, it observed that it was impossible to predict what might have happened to Meadhbh if key pieces of information had been provided, if she had started travelling towards Dublin and if there had been an awareness that the Air Corps fixed-wing aircraft was available at 10.30pm.
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