Organisational issues are now recognised as key factors in the effective use of information technology (IT). This paper extends our knowledge of these issues for large complex distributed organisations. It is based on an analysis of the failure of a large IT system selected by a major state public health service for Statewide implementation. The system selected was well proven overseas, was implemented through a pilot process, yet was withdrawn because it did not meet requirements. The issues which are dealt with include the nature of the organisation and its interaction with the implementation strategy, the nature of decision-making, the contrast between the incentives and perspectives at different levels, ownership of the program, management of skills and the impact of instability and complexity. The option of decentralised IT management is raised and the advantages of common systems discussed. A proposal is ventured for managing such developments while maintaining essential commonality. The paper demonstrates that the environment of large complex distributed organisations introduces a complex of issues that are not normally considered in implementation strategy.