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On 12th August 2011, the Health Information and Quality Authority (HIQA) published its report into the circumstances that led to the failed transportation of Meadhbh McGivern for transplant surgery on 2nd July. It's Chief Executive; Dr Tracey Cooper rightly described the events as "a devastating outcome for Meadhbh". While it was clear from the findings of the Inquiry that the people involved in attempting to get Meadhbh to London entered into what he described as "desperate means to try to do so", the net result was that they failed to do so in the absence of any organised or managed system and because they lacked the required knowledge of logistics to adequately do so. While 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 serious questions remain to be answered about the decisions made and the overall responsibilities of a number of the key players involved in the process.

The Authority established that there were three key pieces of information that were not provided on the night which were; the reduced timeline involved due to the type of donor liver being offered, the provision of an accurate estimated time of arrival for the Sligo Irish Coast Guard (IRCH) helicopter to arrive in London when it selected as the a viable means of transportation which contributed to a series of critical decisions being made during the process leading to the transportation failure and a critical absence of knowledge of air transport and the precise timelines involved. The report also found that there was the absence of clear processes with re-visit protocols to check if State aircraft had become available as time passed as well as ineffective and multiple communications and a lack of effective contingency planning. There was no evidence that checklists were developed or used for minimising error and the process relied on the individual experience of the people involved in a system that ultimately "was not designed to be reliable".

Report makes 17 national recommendations

Given that report makes it clear that “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,” it is reassuring to note that “all of the agencies involved on the night have already made changes to improve the process”. The Authority makes 17 national recommendations, which address the improvements identified from the review 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 (HSE/NAS), which will coordinate all of the transport arrangements 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.

It is refreshing to note that the HSE is required to work with the relevant agencies to coordinate an overall national implementation plan for the recommendations within one month, and regular progress reports are to be provided to the Minister for Health, HIQA and made publicly available. However, given the specific and understandably narrow focus of the report, there is a real danger that some of the underlining issues, particularly operational issues and policy issues relating to the provision of services by the Air Corps or IRCG, may not be adequately addressed.

Reaction to the report

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. Health Minister James Reilly welcomed the publication of the HIQA report and acknowledged the need for a single central control system for making aeromedical transport arrangements for transplant patients and their families. Minister Reilly also confirmed that officials from the Department of Health will be working with the HSE and with officials from the Departments of Transport, Defence and the relevant agencies to help implement the report's recommendations. Commenting on the report, Joe McGivern, Meadhbh’s father said that his family could not “compliment the inquiry team enough for all they have done, their professionalism, empathy, and - most importantly - their findings and recommendations”. “Every family of every transplant patient in Ireland will acknowledge this and follow the implementation process with great interest. Its findings have confirmed what we had thought - there was never a plan in place” he added. Describing the findings of the 78-page report as “frightening” he added “We are glad that we brought this to the fore. Had we stayed quiet on this, nobody would ever have known of the lack of plans and protocols”. “The central thread of the report, from my reading of it, is that there was no evidence of governance or accountability in relation to transport arrangements for transplant patients - at any stage” he added. While it is commendable that the parents of Meadhbh, Joe and Assumpta McGivern, had clearly outlined that one of their desired outcomes was “not to assign blame to any person or persons” nevertheless there needs to be clear accountability, particularly where poor decisions were made.

Questions remain

While the report is specific both in terms of its findings and recommendations it is much weaker in looking at the overall context of the State requirements for the provision of air services and helicopter air ambulance in particular. Numerous external reports have recommended the avoidance of the proliferation of special purpose agencies and in particular to seek to have the majority of the states air requirements to be sourced from a single agency. For example rather than having the Air Corps operate on an “as available” basis and the IRCG backing them one or other of them should have responsibility. Numerous recommendations have also been made on the need for clear Service Level Agreements (SLA) to be signed. It emerges from the report that no SLA is in place with the IRCG and that the IRCG proposes to increase its role in air ambulance in the future when it receives its new Sikorsky S.92 helicopters (the first of which is to be put in place by July 2012). The report states that “the new helicopters will be HEMS (Helicopter Emergency Medical Service) compliant” and regular readers will know that there is a huge difference between a HEMS service and the air ambulance transport service currently provided. Previous reports commissioned by the Department of Health have stressed that given its costs and the infrequency of need a HEMS type service cannot be justified.

The role and expertise of Emergency Medical Support Services (EMSS) has been questioned in the report. They had “an arrangement” from 2001 with a unit’ of Our Lady’s Children’s Hospital Crumlin, Dublin (OLCHC) through a memorandum of understanding, to coordinate the medical transportation of children from their homes to King’s College Hospital, NHS Foundation Trust, London (KCH) for liver transplantation. This service had previously been provided on a less formal basis between 1999 and 2001. From 1999 to 2007, EMSS reported that it had coordinated the travel and transportation for 49 children from their homes to KCH for assessment or transplantation. In 2007 a SLA was agreed between the Departments of Defence and Health, in consultation with the HSE, for the provision of air ambulance services by the Air Corps and the coordination of these services by the HSE was put in place. From then on the role and responsibilities was surely questionable. One particular concern that arose in the HIQA report was that OLCHC 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”. However, at the time of incident, they had contracted that role to EMSS although since the introduction of the SLA in 2007, EMSS’ main role was only the sourcing a private air ambulance when there was no State asset available and making all the arrangements around the transportation on either side of the air transport element. The report revealed that because of this it was agreed by the HSE and the OLCHC that for all new patients who were put on the transplant list, the HSE and OLCHC would take on this role without the need for EMSS. Consequently, in May 2011, OLCHC notified EMSS of its intention to terminate the memorandum of understanding with effect from 31st July 2011. At that time, EMSS was coordinating the arrangements of three children including Meadhbh. Her family were advised by OLCHC that EMSS was the sole and only point of contact for the transfer to KCH and indeed Joe McGivern had were in regular contact with them and had on a number of occasions, discussed the distance and travel times to Dublin, Belfast, Sligo and Knock airport and had also advised them of the GPS coordinates of Ballinamore football pitch (five minutes away from the family home).

The second major issue is why the Air Corps were only contacted on two occasions in the whole process where 78 calls logged were made between the various interests. The protocols in place on that night meant that EMSS, as the first organisation to become aware of the need for air transport had to immediately notify HSE Ambulance Control to contact the Air Corps to source an aircraft. In line with its SLA, the Air Corps was asked to give a go/no go decision within 30 minutes. (However, the stated timeframe for a go/no go decision in the SLA is 15 minutes). The HSE/NAS queried the timeline and was advised by EMSS that no definite timeline had been given. EMSS also contacted Meadhbh’s father and advised him to ‘stay put’ while they organised the air travel. The HSE/NAS contacted the Air Corps at 20.50 requesting a Priority Level 1 air transport (requiring an aircraft to be scrambled within 60 minutes) from Leitrim to London for a transplant with a possible pick-up in Knock. The Air Corps responded that it had no aircraft availability for a priority level 1 mission as only the Gulfstream IV was in service (both CASAs and the Learjet were grounded for maintenance) and this was overseas in Nice with the President and it had an estimated departure time of 21:30 but that this was yet to be confirmed. A second call from the Air Corps to the HSE/NAS advised that the Gulfstream IV was estimated to land in Baldonnel at approximately 22:30. The use of the standby helicopter was also discounted at this stage by the Air Corps as it was involved in an air ambulance spinal transfer of a patient as was the option of using another helicopter due to the time required (i.e. outside the Priority 1 range) to gather the flight crew and have a helicopter airborne. No further contact was made with the Air Corps to access the progress of either aircraft even though the HSE/NAS had been advised by EMSS that no definite timeline had been given. The report states that once the Air Corps conformed that it had not got a asset available and had decline the mission, the decision was not re-visited which it says was consistent with the SLA which outlined single request steps that were to be followed.

The HSE/NAS then contacted the IRCG through its National Maritime Operations Centre in Dublin at 20:08 requesting a helicopter for priority level 1 air transport from Leitrim to London for a transplant as no Air Corps aircraft available. The IRCG replied that it had no helicopter available until midnight. The IRCG provide thought it’s contractor CHC (Ireland) a 24-hour a day search and rescue (SAR) helicopter service, with six Sikorsky S.61 Helicopters from four airport bases at Dublin, Shannon, Waterford and Sligo. The helicopters are designated wheels up from initial notification in 15 minutes during daylight hours and 45 minutes at night. With no SLA with the IRCG it is not clear whether they are made available when not required for SAR operations or indeed what is their required response times to a HSE/NAS request. There was also no understanding or defined terminology in place in relation to urgency of the request. Apparently, the IRCG Dublin based helicopter had developed a failure of a component (of the aircraft’s back-up hydraulic system) and the crew were en route to Shannon to pick up the spare helicopter and fly it back to Dublin for 23:00. Consequently, the Sligo helicopter was providing the contracted service for the top half of the country and could not be tasked. The availability of the primary Shannon helicopter or the two Waterford machines is not mentioned in the report. At that stage the best option was the Air Corps Gulfstream IV (or their duty helicopter). Indeed scheduled air transport out of Dublin seemed to have been totally overlooked at this stage (there were two options up to 22.00 with Ryanair) and the extraordinary decision to tell the McGiverns to ‘stay put’ at home was a critical point in this process. EMSS said it was “normal practice” for a patient to stay at home until an aircraft and airport were confirmed but HIQA was not provided with documentation that outlines this practice. The McGiverns with a Garda escort was ready to go at 19.30 and their immediate dispatch to Dublin would have certainly improved their options for transport that night.

From then on all efforts were put into to sourcing a private air ambulance until for reasons that remain unclear the issue of using the IRCG was revisited. Although their availability and timelines had not changed and by this time OLCHC’s air ambulance provider had confirmed that an aircraft and crew sourced this was stood down in favour of using the IRCG Sligo based helicopter. OLCHC had contacted the HSE/NAS directly to advise that it had sourced a private aircraft which could transfer from Knock or Dublin with an earliest approximate departure time of 23:30 with an arrival time at Stansted Airport outside London at 00:35. This is a critical point in this process with the decision to cancel the private fixed-wing air charter in favour of the IRCG Sligo helicopter was made on the erroneous assumption that the helicopter travel time from Sligo to London was one and a half hours. Other than for reasons of cost it is not clear why the IRCG was contacted and subsequently tasked with the mission although it appears that the use of the IRCG Sligo helicopter was suggested to HSE/NAS by EMSS at 20.57 after they had requested RAF assistance through it’s UK air ambulance agent at 20.44. The Air Corps would probably have better dealt with such a request, but EMSS had no direct contact with the Air Corps that evening.

It was until slightly after 22:00 that the McGiverns were advised to go to Sligo (even though at that stage no take off time had be advised. They informed EMSS that they had arrived at 22:56 and shortly afterwards the helicopter crew advised Meadhbh’s father Joe that the take-off time would be 23:30 with an estimated four hours’ travel which included two stops for refuelling. Joe contacted EMSS who in turn contacted the on-call Liver Transplant Coordinator with the new estimated 04:00 time of Meadhbh’s arrival to KCH. The on-call paediatric liver transplant surgeon was contacted and made the decision that the donor liver should be offered to another patient. At approximately 23:20, the on-call Liver Transplant Coordinator relayed this information to EMSS. At 23:23, Meadhbh and her parents were in life jackets and about to board the IRCG helicopter when Joe received a call from EMSS advising them to ‘stand down’ as KCH required them to be at the hospital before 02:00 if the transplant surgery was to go ahead. Given that the availability of either of IRCG Dublin or Sligo helicopters were both like to the available for 23:00-23:30 and that the flying time from Dublin was going to be much shorter from Dublin it is not clear why the IRCG did not suggest this.

Lessons learnt

While the decision to establish a National Aeromedical Coordination Centre and a National Aeromedical Coordination Group as well as a ‘Live’ information management system which details the availability of each State asset at any one point in time with detailed classification information available regarding the travel times, refuelling requirements, capacities and ranges of each of these assets and of changes in the status of availability of each together with a transport logistics plan for each patient on the transplant list is welcome, there needs to be clear levels of responsibility between the IRCG and the Air Corps. It needs to be clarified if the IRCG assets are primarily for SAR and how their tasking for air ambulance will affect their SAR coverage and availability. For the Air Corps the need to dedicate assets to the air ambulance standby role, particularly the Learjet needs to be considered although this would possibly require the decision not to undertake any major work on the Gulfstream IV to be reversed. The whole question of the IRCG future role in HEMS or purely air ambulance transported needs to be assessed in the context of their new contract with CHC. Until these issued are resolved, the lessons of the Meadhbh McGivern incident will only be partially learnt.