THE SYSTEM put in place for transporting patients abroad for treatment was not designed to be reliable, the Health Information and Quality Authority has found.
The conclusion was one of the key findings in the authority’s report into how a 14-year-old Leitrim girl missed the opportunity to receive a liver transplant in London.
The report said there was no overall effective governance of the Treatment Abroad scheme service model. It also found that no one person or agency was in charge of organising the travel arrangements.
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 authority’s investigation was ordered by Minister for Health James Reilly after it emerged that on July 2nd this year, Meadhbh McGivern from Ballinamore, Co Leitrim, had not been transported to King’s College Hospital in London in time for a transplant operation.
Authority chief executive Tracey Cooper said yesterday that on the night in question, all the ingredients were present for “a perfect storm”, which, together, resulted in the failure of the various State agencies to transport the patient to London.
She said the number of State aircraft or helicopters available to fly Meadhbh to London was significantly diminished. Private aircraft were also in short supply.
Key information was also not provided on the night, while a number of assumptions had been made that turned out to be wrong.
Dr Cooper said it was clear that people involved in attempting to get Meadhbh to London entered into desperate means to try to do so.
However, she said this was “in the absence of any organised or 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 for the transportation for Meadhbh.”
The report found there were three key pieces of information that were not provided on the night, which resulted in a series of critical decisions being made that contributed to the failed attempt to bring Meadhbh to London. It said these were:
The fact that the liver available was from a non-heart beating donor (where death followed cardio-respiratory arrest) and therefore the time frame to transplantation was shorter than usual. This was the first occasion the Irish authorities had dealt with such a donor liver;
The required arrival time at the hospital in London for a viable transplant surgery to take place;
The provision of the earliest estimated time of arrival for the Coast Guard helicopter in Sligo into London.
The report said there was an absence of knowledge about the transport of patients by air and the precise timelines involved. It also said there were no protocols for health bodies to recheck if State aircraft had become available as time passed.
The report was also critical of ineffective communications and a lack of effective contingency planning.
It added that there was no evidence that “checklists” were developed or used for minimising error. It said 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 July 2nd, the system was not designed to be reliable.”
The report found that there had been confusion between Our Lady’s hospital and the HSE’s National Ambulance Service in relation to their respective roles and responsibilities for the logistics of the process. It said Our Lady’s Hospital in Crumlin had recently taken on the roles of co-ordinating the road and air travel, including aircraft logistics and flight times and the booking of private air ambulances when State assets were not available, “without the required skills and competencies to effectively undertake the function and or to understand or consider the associated risks”.
In the absence of key pieces of information there were four critical decisions made that contributed to the failure to successfully bring Meadhbh to London, the report found.
This included the decision made at 19.45 for Meadhbh and her family to remain at home in Ballinamore and not to travel to Dublin.
It also included the decision made between 21.45 and 22.00 to cancel a private air charter organised by Crumlin and to accept the offer of the Coast Guard helicopter in Sligo – in keeping with the official protocol that State aircraft must be used if available.
The report said this decision was based on the incorrect assumption that the helicopter travel time from Sligo to London was an hour and a half.
Another key decision came at 23.15 when it was confirmed that the Coast Guard helicopter would take four hours to make the journey to London, that the HSE National Ambulance Service was not advised and it was unable to revert back to the Air Corps to see if one of its aircraft was available at that time.
“The absence of knowledge about aero-medical logistics, precise timelines, clear processes with revisit protocols, a single accountable person and agency in charge, multiple communications handoffs and the lack of effective contingency plans exacerbated the situation and led to the final outcome,” the report stated.
