The HSE is today publishing the report of the former Chief Justice Mr Frank Clarke SC on the independent investigation that he led into matters connected with the tragic death of Aoife Johnston at University Hospital Limerick on December 19th, 2022.
The report was commissioned by the CEO of the HSE Bernard Gloster after he received the report of a Systems Analysis Review (a SAR report), prepared under the HSE’s National Incident Management System (NIMS). Bernard Gloster commissioned the Clarke report having considered the conclusions of the SAR and having determined that further investigation was necessary.
Mr Clarke was asked to undertake an independent investigation on the circumstances surrounding the death of Aoife and to prepare an evidence-based report in the context of very clear Terms of Reference.
In his report Mr Clarke identifies and considers a number of issues and these include:
*Several systems and pathways of care in the Hospital which appear to have been either in place and not implemented or not in place other than in an ad hoc way. These included critically the sepsis pathway and the escalation protocol for managing the capacity challenge.
- Concerns about gaps in communication between the senior management of the hospital and the front-line managers running the services on the ground.
- The capacity issues impacting the hospital post reconfiguration and having regard to the population growth and the demand on the particular weekend.
Bernard Gloster said: “I want to thank Mr Justice Clarke and his team for the excellent report and the thoroughness of the work. This report has enabled us already to bring clarity to the concerns that arise from Aoife’s case based on a consideration of the evidence. It has given us a pathway to both learning and accountability. That accountability is and will be pursued fairly and appropriately in a confidential process. The learnings from the report and the recommendations are all being actively considered in the many aspects of improvement that are underway and indeed have relevance to assisting the overall patient safety agenda in all our settings.”
Mr Clarke’s report does not make adverse findings in relation to any individuals. The HSE is conscious of the criticism of this and would wish to emphasise the following by way of response.
- Mr. Clarke made it clear in Chapter 10 that the Terms of Reference did not allow for the making of adverse findings against individuals or resolving conflicts of fact. If the Terms of Reference had provided for such findings it would have been a much more prolonged process which would have had to ensure that any individuals, who might be the subject of any such adverse finding, were given the full opportunity (with legal representation etc.) to present their own side of events and challenge any evidence through cross-examination. Mr. Clarke made it clear that “it is not possible to have it both ways and have a timely resolution while at the same time complying with the obligations of procedural fairness.”
- Most importantly, if the report, commissioned by the HSE CEO, had included such adverse findings against any HSE employee it would have represented an unlawful contravention of their legal and contractual rights, and the Report would have been likely to be struck down in the courts.
- He went on to say “… it would not have been possible to conduct the sort of process which might give rise to the possibility of adverse individual findings in anything remotely like the timescale specified in the Terms of Reference.”
The HSE is also today publishing the report of the UHL Support Team, which was established on April 30th last to Support the Region in addressing some of the pressures that are experienced there. The team advised on several actions designed to ease overcrowding and pressures in the Emergency Department at University Hospital Limerick. The HSE is grateful to Ms Grace Rothwell, National Director, Ms. Orla Kavanagh Director of Nursing and Retired Emergency Medicine Consultant Dr Fergal Hickey.
Commenting further on today’s publications Bernard Gloster said “Mr. Justice Clarke has given a timely and sound report, probably the most such that I can recall in my career. We failed Aoife and our failure has resulted in the most catastrophic consequences for her and her family. It is only right and proper that there is appropriate accountability based on evidence, facts and that it is lawful in how it is pursued. We now have that. It is also important to have learning to improve patient safety based on that same evidence. When all is said and done today must be about Aoife and her family, recognising that all the reports and processes will not undo the harm caused to them. For that we are and must remain truly sorry. May she rest in peace.”
