FORMER Chief Justice Frank Clarke is to conduct a formal investigation into the death of 16-year-old Aoife Johnston at University Hospital Limerick exactly one year ago.
Ms Johnston, from Shannon in County Clare, presented at University Hospital Limerick (UHL) on December 17, 2022, and died two days later after spending 12 hours on a trolley in the hospital’s emergency department (ED), which was overcrowded and understaffed, according to an internal HSE review.
Having considered this review which “is significant in its findings about the care of Aoife and the operation of the hospital”, the HSE said its chief executive, Bernard Gloster, was “satisfied that questions of accountability need to be addressed”.
A statement by Mr Gloster confirmed that he has “appointed the former Chief Justice Mr Justice Frank Clarke (retired) to conduct a formal investigation into all of these matters, to make findings and to report to me, and the outcome of this investigation will inform any further decisions to be made.”
Mr Gloster apologised “unreservedly to Aoife’s family, recognising no words of mine can ever take away their loss”.
“I do however assure them that the issues raised in the report will be investigated thoroughly.”
Ms Johnston’s family received the unpublished internal report into Aoife’s death last week, nine months after it was initially expected.
A damning report
The damning report, revealed by the Sunday Independent, found Ms Johnston waited 12 hours to be seen by a doctor to receive treatment for sepsis in what was a breach of national sepsis management guidelines.
By the time Aoife received the appropriate care, her condition had deteriorated beyond recovery, the review found, and she died two days later.
Overcrowding was “endemic” in the hospital, and there were insufficient nurses in the emergency department to care for patients as well as insufficient emergency medicine doctors to deal with the number and acuity of patients, the report found.
It also highlighted a series of governance failures and missed opportunities as Aoife waited for life-saving treatment.
The unpublished review, given to the family’s solicitor Damien Tansey SC, has caused alarm at the highest levels of the health service.
In the wake of the report, Health Minister Stephen Donnelly wrote to the chair of the HSE about the “clear failures in clinical and wider governance at the hospital” and expressed his deep concern about staffing levels in the emergency department on the night Ms Johnston presented there.
Staff shortages flagged
Two days before she died, Ms Johnston arrived with her parents at an emergency department in chaos, it was reported.
The sixth-year student had travelled with her parents from their home in Shannon, expecting she would be treated urgently as her symptoms included vomiting and diarrhoea, and her condition was worsening.
The family arrived after 5pm on a Saturday, one of the busiest times at the hospital, sources told the Limerick Post.
The report found that patients with varying degrees of sickness and injury were on chairs and on the floor. Trolleys were stacked up back-to-back on corridors with patients waiting to be admitted to wards.
The HSE said at the time that 251 patients attended UHL’s ED on the day Aoife presented and it had been overcrowded for days beforehand.
Staff shortages had been flagged with management over the weekend, yet the review into Aoife’s care found UHL had no contingency plans in place to prepare for these pressures on the emergency department, according to the Sunday Independent.
Aoife was triaged an hour and a half after presenting at the ED, yet the National Emergency Medicine Programme recommends that most patients be triaged within 15 minutes of registration.
Aoife had bacterial meningitis, but her triage noted possible sepsis. She was classified as a Category 2 patient, meaning she needed very urgent treatment and should have been seen within 15 minutes as, unless treated quickly, sepsis can lead to septic shock, multiple organ failure, and death. The review of Aoife’s care suggested she should have been administered what is called a potentially life-saving “sepsis bundle“ within an hour.
Consultant declined call for help
Aoife waited on a chair in the the ED while her condition deteriorated with each passing hour as the trolley crisis in the department deepened.
It has been reported that two consultant doctors were called to help ease the pressure in the ED — one obliged while the other declined and reportedly told the HSE review team that it was not the function of an emergency consultant to “sort out overcrowding”.
UHL’s “escalation” plan or full capacity protocol — a national directive to ease overcrowding which should have been activated to ease overcrowding in the ED — was not triggered that night, the review found.
The review of Aoife’s care states her parents made “multiple attempts to highlight her condition” with emergency medicine doctors who were busy with other patients.
The family’s solicitor, Damien Tansey, told the Sunday Independent that the Johnstons were “at their wits’ end, constantly and for the entire night” as they desperately tried to get the teenager seen by a doctor.
It has been reported that Aoife eventually received a medical review at 6am, after a nurse once again asked a doctor to see her. She then received treatment, but at that stage it was 12 hours too late, the review found.
‘Let down by the systems in place’
Ms Johnston was admitted to intensive care later on that Sunday, but she was pronounced dead at the hospital on the following day, Monday December 19.
The review found that Aoife’s parents “did everything possible” to care for her, but that she and her family were “let down by the systems in place in the emergency department at UHL”.
UHL is consistently the most overcrowded hospital nationally and is the only 24-hour emergency department for a catchment of almost 400,000 people across the Mid West, following the closure of 24-hour EDs in Ennis, Nenagh, and St John’s hospitals in 2009.
“There is little apparent understanding of the risks and inefficiencies caused to patient care by a crowded environment by the hospital system,” the review states.
Professor Colette Cowan, chief executive of UHL, signed a letter of apology to the Johnston family for the missed opportunities and “failures” in Aoife’s care, and acknowledged that national guidelines on sepsis were not followed in her case.
