Health Service Executive (HSE), Serious Incident Management Team2012-02-272012-02-272011-08http://hdl.handle.net/10147/212989Ms Mc G is designated as a ‘priority’ patient on the liver transplant list; she is a fourteen year old girl who lives in Co Leitrim with her parents and an older sister. During the evening of the 2nd July 2011 the family of Ms Mc G were contacted by the Transplant Co-ordinator at Kings College Hospital London and informed that a liver had become available for Ms Mc G. Due to delays in securing the appropriate transport to effect the transfer of Ms Mc G and her parents within the time-frame required, Ms Mc G and her family were informed that she should not travel to London to undergo the liver transplant procedure. Ms Mc G and her family returned home during the early hours of the 3rd July and the organ was transplanted into another patient awaiting a donor liver from the transplant waiting list. This incident was deemed by the Health Service Executive (HSE) to fall into the ‘serious adverse incident’ category. On this basis an investigation of the incident was commissioned by the Health Services Executive Serious Incident Management Team. The aim of the investigation was to: - Establish the factual circumstances leading up to the incident - Identify any Care/Service Delivery Problems that contributed to the incident - Identify the contributory factors that caused the Care/Service Delivery Problems - Recommend actions that will address the contributory factors so that the risk of future harm arising from these factors is eliminated or if this is impossible, is reduced as far as is reasonably practicable.enCC-BY 4.0https://creativecommons.org/licenses/by/4.0/HEALTH SERVICES AND THEIR MANAGEMENTPATIENT SAFETYQUALITYQUALITY CONTROLTRANSPORTReport