THERE WAS no overall effective governance of the Treatment Abroad Scheme service model. The “overly administrative focus” on the funding and reimbursement of transport diverted attention from the safe and timely transfer of care for patients.
* There was no single co-ordinating agency or person with overall accountability for the transportation of Meadhbh McGiven.
* There was no evidence that Our Lady’s Children’s Hospital Crumlin, the Health Service Executive corporately, or the National Ambulance Service within the HSE understood or managed the risks of the model of care.
* There was confusion between the HSE’s National Ambulance Service and Our Lady’s Children’s Hospital Crumlin in relation to who was responsible for transfer and transport logistics.
* There were no mitigating actions or contingency plans in the event of no State aircraft or helicopter or private air ambulance being available.
* Where individual agencies or service providers had their own governance arrangements for their role in the process, these were not sufficiently co-ordinated with other agencies or providers.
* Our Lady’s Children’s Hospital Crumlin did not have the required competencies to undertake the role of co-ordinating the road and air travel for children going from home to King’s College Hospital.
* Multiple agencies and service providers were all contributors to co-ordinating a patients transfer for organ transplantation. In this case these included Kings College Hospital; the HSE’s National Ambulance Service; Our Ladys Childrens Hospital; the Air Corps; the Irish Coast Guard; the private service provider Emergency Medical Support Services; and the patient’s family.