THE HEAD of Ireland’s health service Bernard Gloster has issued a groveling apology to the family of Aoife Johnston, after an expert former judge’s report was published into Aoife’s death amid care failings at University Hospital Limerick.
Aoife, who should have been given life-saving medicine within 10 minutes of arriving at UHL, did not receive it until 13.5 hours later, when it was too late for the 16-year-old girl from Shannon, Co Clare.
Former Chief Justice Frank Clarke’s report concluded that Aoife’s death “was almost certainly avoidable”.
And he gave a stark warning that unless the fundamental problem of overcrowding is tackled there could be another such tragedy.
Acknowledging failings in Aoife’s care at UHL two years ago, HSE boss Bernard Gloster admitted: “We failed Aoife and our failure has resulted in the most catastrophic consequences for her and her family.”
“For that we are and must remain truly sorry. May she Rest In Peace,” Mr Gloster added.
The Johnston family, who had sight of the report before it was published, have already said they are bitterly disappointed that it does not name people involved and does not resolve any of the conflicting accounts.
As the long-awaited report was being published, UHL remained the most overcrowded hospital nationally, with 80 patients languishing on trolleys — just as tragic Aoifa did in the hours leading up to her avoidable and shocking death on December 19, 2022.
Aoife had been referred to UHL by a locum GP service with queried sepsis which requires urgent treatment.
She should have been treated for sepsis within 10 minutes of being triaged, but she died of meningitis, brought on by sepsis, after she was left throwing up green fluid on a chair and trolley for 13.5 hours without antibiotics.
The report which did not name any staff members at UHL, found the hospital’s emergency department was “significantly understaffed” and had an “inadequate” system for escalating staff concerns about deteriorating patients.
UHL requires hundreds more beds to meet the demand of a catchment of 400,000 plus population, with only one 24-hour emergency department across Limerick city and county, the entire county Clare, north Tipperary, parts of North Cork and North Kerry.
However, Friday’s published report by esteemed former Chief Justice, Frank Clarke, warned, that despite investment in bed capacity since Aoife Johnston’s death, the “risk of reoccurrence” of another patient death at UHL in similar circumstances “will inevitably be present” if additional investment is not provided.
Mr Clarke found that another deadly scenario “will not be further minimised without addressing the fundamental problem of overcrowding”.
Clarke emphasised what patients, their families, patient advocate groups, and some politicians have warned for years, that “unless and until” a shortage of beds at UHL is tackle, it “will unfortunately but regularly be under pressure”
Aoifa should have been given “vital” antibiotics within 10 minutes of being triaged at the hospital.
The Clarke report found that nurses and doctors were unaware Aoife was flagged as potentially having a sepsis infection.
However, Ms Johnston’s inquest heard that after Aoife was triaged, a nurse escalated her concerns around sepsis to a doctor in the Resus Department of the hospital, however Aoife was not admitted there.
Mr Clarke identified systems and pathways of care appeared not to have been either in place nor implemented or not in place other than in an ad hoc way.
He also highlighted concerns about gaps in communication between the senior management of the hospital and front-line managers running the services on the ground.
Bernard Gloster pledged there would be accountability for Aoife’s death.
“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.”
“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.”
The Minister for Health, Stephen Donnelly said he has asked the Heath and Information and Quality Authority (HIQA) “to lead a review into urgent and emergency care capacity in the Midwest region, including to determine whether a second Emergency Department is required”.
The Irish Nurses and Midwives union, (INMO) welcomed Friday’s report publication, but warned that it had been “sounding the alarm on issues of patient safety due to unsafe staffing levels in UHL at local, regional, national and governmental levels as far back as 2016”.
Limerick Sinn Fein TD, Maurice Quinlivan, who has been a loud voice in calling for additional investment at UHL said the lack of capacity at UHL “has been known for the last fifteen years”.
“A litany of failures in management meant that, despite the emergency department being massively overcrowded, escalation and crisis management protocols were not implemented.
“As a result, Aoife was placed in the wrong part of the hospital because the resuscitation area, where she should have been as a suspected sepsis patient, ‘was already grossly overcrowded’,” he said.
