But the program continued to enroll patients, market its services and try piecemeal fixes that ultimately failed, according to interviews and documents obtained by The Times.
Administrators resisted closing the transplant center until Thursday, hours after the federal government revoked its certification. They believed that the program, the only one in Orange County, was important to the region and to the reputation of the hospital, which is in Orange.
"If we look back at it now, it's easy to see that plans put in place turned out not to be successful," UC Irvine Chancellor Dr. Michael V. Drake said Friday. "It's harder to see that in the present than it is to see it in hindsight."
The long, slow crash had begun by 2001.
That year, 35 people died while waiting for new livers -- more than double the previous year. Just 15 received transplants.
Alarmed, Dr. John Hoefs went looking for answers. He discovered that the problem went beyond a shortage of livers. Even when seemingly suitable livers were offered for patients, the transplant program was turning the organs down.
Hoefs, a UCI liver specialist who is not a transplant surgeon, said he relayed his concerns to hospital administrators. He said he felt confident that the hospital was responding.
Even so, he steered some of his sickest transplant candidates to other hospitals to increase their odds of getting a liver.
"I don't have that kind of loyalty that I would ever sacrifice my patients' best interest," he said.
It didn't take long before doctors, nurses and other employees also grasped that the transplant program was in deep trouble -- mainly because it didn't have enough surgeons to operate, according to interviews with hospital leaders, staffers and former staffers.
"Everybody became aware," Hoefs said. "Suddenly, we were dealing with a problem."
The hospital faced a dilemma: Publicly revealing the problems could lead to the program's demise, but keeping patients on the waiting list could prove fatal.
Administrators took the risk that they could make things better.
They tried to hire new surgeons. They crafted a marketing campaign to attract new patients. They begged regulators for more time. They sidelined people who complained and looked past doctors' egos and what Hoefs described as their "peculiar behaviors." They hung on by persuading two doctors from UC San Diego to work part-time.
All the while, they kept adding patients to the waiting list -- until this week.
In pulling the program's certification Thursday, the U.S. Centers for Medicare and Medicaid Services said that not enough transplants were being performed to maintain proficiency. The few patients who received new livers were dying at an unacceptable rate.
Dr. Ralph Cygan, UCI Medical Center's chief executive, insisted that the university placed the patients' best interests first. But he acknowledged that he would have acted differently had he known the problems would take so long to fix. "I would have insisted that we would have closed the program until we were in a better position," he said.
But now, families of patients who died are left to wonder whether those lives might have been saved.