The Health Information and Quality Agency also found there was no evidence that Our Lady's Children's Hospital Crumlin, the HSE or the National Ambulance Service understood or managed the risks of treatment.
There was also confusion between hospitals and emergency services as to who was responsible for transport and evacuation logistics.
Dr Tracey Cooper, chief executive of HIQA, said: “On the evening of 2 July 2011, the transport for a liver transplant went awry, with tragic consequences for Mr Meadhof. It is clear from our investigation that those attempting to transport Mr Meadhof to London resorted to desperate measures, but this had no organised or controlled system, nor the logistical knowledge required to transport him properly.”
Mr McGivern, from Ballinamore, County Leitrim, had been preparing to board a Coastguard helicopter in Sligo when he and his parents Joe and Assumpta were told they would not make it to King's College Hospital in London in time for 2am.
The family was also told that the operation had to be rushed because the new liver would come from a “non-breathing” donor.
But four hours had passed since the McGivern family was offered the life-changing transplant procedure.
Health Minister Dr James Reilly, who called for the HIQA investigation, said Government departments of Health, Transport and Defence had been tasked with setting up a new 24-hour coordination unit with the Health Service Executive (HSE).
“To prevent tragic outcomes like those experienced by the McGivern family, we need clear and robust processes to organise and source the timely and appropriate transport of organ donations when they become available,” Dr Riley said.
Dr Riley said transplant failures must never happen again and welcomed plans for a new National Aeromedical Coordination Group.
“I am confident that the report's recommendations will be implemented effectively and practically so that Irish patients who need a life-saving transplant but cannot receive one at home can be confident that they can receive a suitable transplant elsewhere,” he said.
HIQA warned that there was a clear excessive focus on the costs of transporting patients to London and who would pay for them.
“The administration's excessive focus on travel and transportation funding and reimbursement has diverted attention from the safe and timely transfer of care to patients,” the report said.
The McGiverns were informed by staff at King's Hospital at 7.20pm on Saturday that a liver was available for his potentially heart-stopping son.
Several agencies were involved in securing the transport, including the HSE, Coastguard, Department of Transport, Air Corps and Emergency Medical Support Services (EMSS).
Records of calls between some of the agencies and the family suggest there was a breakdown in communication between the teams involved.
HIQA's investigation found that agencies relied on “the individual experiences of people involved in a process that was inherently dangerous and logistically challenging because of its complexity and the impact on children if it failed”.
Watchdog groups said the system had worked in the past but was not designed to be reliable.
The report highlighted a lack of overall coordination regarding communications, logistics and the deployment of “air ambulance” resources.
Dr Cooper added: “It is urgent that we learn from Mr Meadhov's experience and take the necessary steps as a country to reduce the chances of such an incident happening again. All of the agencies involved on that night have already made changes to improve their processes.”
HIQA discovered three key pieces of information that night that had not been properly shared between agencies.
:: Due to the type of liver provided by the non-heart-beating donor, the deadline for the surgery was shorter than usual.
:: The latest time Meadhbh must arrive at King's.
:: Estimated arrival time of the London Coast Guard helicopter shortly after it was selected as the available and viable air ambulance transport option.
Hika found several factors that exacerbated the failure, including a lack of knowledge about transporting patients by air and the exact schedule involved, as well as a failure to check and recheck whether the national jet had permission to fly.
The Air Corps, Coast Guard and other service providers have been asked to support the new 24-hour coordination unit.
The HSE has been given one month to draw up a plan to meet the report's 14 recommendations.
