'Inherently risky' system to blame for failure to transport transplant candidate Maedhbh

A Health Information and Quality Authority (HIQA) inquiry into the failed transportation of Leitrim girl Meadhbh McGivern for transplant surgery last month has found that an "inherently risky" system that relied on individuals led to the failure.

Fourteen-year-old Meadhbh McGivern from Ballinamore in Co Leitrim has been waiting for a transplant for almost a year, making her the longest person ever to be on the paediatric liver transplant waiting list.

Six weeks ago she got a call from a hospital in London to say a donor was available, but because of a delay in getting transport in place she missed her chance.

Several agencies were involved in making arrangements for transport – the Health Service Executive (HSE), Coastguard, Department of Transport, the Air Corps and the Emergency Medical Support Services (EMSS).

HIQA has found that "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."

HIQA has recommended the establishment of a National Aeromedical Coordination Centre, within the HSE National Ambulance Service, to coordinate all of the transport of patients by air and to be the single point of accountability for the process.

It would be provided by people trained in the required skills and competencies in aeromedical logistics, 24 hours a day and have the support and assistance of the Air Corps, Irish Coast Guard and other service providers.

The HSE is required to deliver a plan to implement its recommendations within one month, with regular progress reports to be provided to the Minister for Health and also made publicly available.