Watchdog blasts liver op failures

A teenage girl missed a vital liver transplant in London because of a lack of leadership and an unreliable system for arranging rapid air ambulance transport, a health watchdog has found.

Meadhbh McGivern lost out on the potentially life-changing operation last month because no-one was in charge and communications on the type of donor and a six-hour surgery deadline had broken down.

A report by the Health Information and Quality Authority (HIQA) has called for a new 24/7 centre to be set up to co-ordinate transfer of patients by air.

HIQA chief executive Tracey Cooper said several state agencies had no organised or managed system or knowledge of logistics to fly Meadhbh to London.

“There was no conductor of the parts of the orchestra, so people were going on in their own little world desperately trying for a successful transportation,” she said.

“But there was no single agency or individual ultimately accountable for ensuring that the right decisions were made at the right time.

“It was really all the ingredients of a perfect storm that night.”

Meadhbh, 14, from Ballinamore, Leitrim, is still awaiting a donor.

A planned Irish Coast Guard transfer to King’s College London was cancelled at the last minute on July 2 as the flight would not have met a 2am deadline for surgery. Several hours had lapsed since the family had been first offered the transplant.

The new 24-hour National Aeromedical Co-ordination Group will be set up by staff from government departments of health, transport and defence along with the Health Service Executive (HSE).

Health Minister Dr James Reilly, who ordered the HIQA inquiry, said the missed transplant should not happen again.

“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.

“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.”

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.

But it insisted the price of an air ambulance to London was not an issue in the McGivern case.

The report said: “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 McGiverns were alerted by King’s Hospital staff at 7.20pm on Saturday July 2 that a potential non-heart-beating liver was available.

Several agencies were involved in trying to secure transport – the HSE, Coast Guard, Department of Transport, the Air Corps and the Emergency Medical Support Services (EMSS).

But 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.”

The HSE and Our Lady’s Children’s Hospital, Crumlin, which had helped to co-ordinate the failed transfer, said they sympathise with the McGivern family and are mindful of the distress caused.

Robert Morton, director of the HSE National Ambulance Service, said all similar patients have since been given individual transport plans.

“This is the first time in our experience that an urgent transfer like this has failed and we have sincerely apologised to the family for the distress caused, and share their ongoing concern for Meadhbh’s health,” he said.

“We will work to ensure that the whole patient transfer system learns from this incident and that we strengthen the service arrangements in line with the investigations carried out.”

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 also 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 HSE has been given a month to develop a plan to meet the 14 recommendations in the report.

As part of a new air ambulance regime the Air Corps and Coast Guard will provide twice daily updates at 9am and 5pm to the National Ambulance Service on the availability of aircraft.

It will also warn the service when an aircraft is on another mission or out of action.