A CRUCIAL change of wording in a report presented to the family of a teenager who died of suspected sepsis after a 12-hour wait in the emergency department of University Hospital Limerick (UHL) has shifted the emphasis away from the hospital’s management team.
A draft System Analysis Report on the circumstances of 16-year-old Aoife Johnston’s death, commissioned by UHL, stated that “there is little apparent understanding of the risks and inefficiencies caused to patient care by an overcrowded environment by the executive management team in terms of the impact on the emergency medicine doctors assessing and managing patients and the nursing staff’s ability to provide safe care.”
However, in a final report, the one presented to the Shannon girl’s family, the reference to the “executive management team” was changed to read “the hospital system”.
The HSE said only the final version of the report had been accepted and that it was “not appropriate” to comment on the draft.
At the beginning of January, the HSE announced a framework for an independent investigation, which is to be undertaken by former Chief Justice Frank Clarke.
It emerged to some outrage last week that the Johnston family had not been consulted about the terms of reference in the investigation. This week, the lawyer for the Johnstons said the family accepted the explanation of Health Minister Stephen Donnelly that no party to the events had been consulted about the framework in order to ensure that the probe be fully independent.
While the Minister would not be drawn on whether or not he has faith in the Limerick hospital management team, HSE CEO Bernard Gloster has intimated that culpability will be applied if the investigation warrants it.
An inquest into Ms Johnston’s death is scheduled to take place beginning April 21 and is expected to run for number of days.
“The family are looking forward to the inquest when an opportunity will be afforded them, through their lawyers, to seek explanations as to why what happened in Limerick happened,” Damien Tansey, senior counsel representing the family, said.
In a statement to the Sunday Independent on the final report, the HSE said that “the System Analysis Review report followed the process as set out in the HSE Incident Management Framework. The final report was accepted and it is not appropriate to describe the detail of its drafting.”
