LAST UPDATE | 20 Sep
THE INDEPENDENT REPORT into the death of Aoife Johnston at University Hospital Limerick has found a series of failings in how the hospital handled her case.
The 16-year-old died of sepsis after waiting on a chair for 12 hours in the emergency department in December 2022.
Long wait times due to overcrowding and a breakdown in communication were among the issues found to have likely contributed to her death.
The report, by retired judge Frank Clarke, found there was a thirteen-and-a-half hour gap between when Aoife was seen by a GP who queried the possibility of sepsis and when she received treatment.
“All of that needs to be seen in light of the National Protocol on sepsis which suggests that treatment should take place within one hour,” it said.
There was also severe overcrowding in the hospital’s emergency department that day.
Patients are triaged in UHL in accordance with the Manchester Triage System. This places patients in categories 1 (the most severe) to 5 (the least acute).
The ideal maximum time to first contact with a treating clinician for a patient categorised as Category 2, as Aoife was, is 10 minutes, the report said.
There was “no reality” to patients being seen within that window, considering the number of them and the number of staff members available.
“Indeed, it would appear that it would have taken over 10 hours (as opposed to 10 minutes) to see all Category 2 patients.”
The report said that while it is impossible to determine at which point in the hours Aoife waited that it was “too late” to save her life, “there can be no doubt that the greater the delay the greater the risk of the tragic outcome which ultimately occurred and, consequently, the less the delay the greater the chance of there having been a positive outcome”.
Aoife’s family had received the report some weeks ago and said they were disappointed with its contents.
Their solicitor Damien Tansey told RTÉ that the restrictions imposed on the former chief justice by the HSE “flew in the face of assurances that were given”.
In the report, Clarke says that the terms of reference did not allow for the making of adverse findings against individuals or resolving conflicts of fact, contrary to what Aoife’s family had called for.
The HSE said that this made for 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 to present their own side of events and challenge any evidence through cross-examination.
Clarke said: “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.”
The report gave a series of recommendations, including that the HSE should consider whether GPs could give initial treatment to patients suspected of having sepsis, in an effort to avoid a long wait.
It said the HSE should consider ways patients in urgent need of treatment could be traiged more quickly in at an emergency department.
A patient, once seen and prescribed medication by a doctor, should not be waiting over an hour, as in Aoife’s case, for those medications to be administered, the report said.
“Equally the ad hoc system of a doctor asking a nurse in a busy ED to administer a prescription to a patient with no prompt follow-up is unsatisfactory.”
The report also recommended reviews into the prescription and administration of medication, as well as the roles of doctors in a busy emergency department.
A study is also needed on how the HSE will respond to an apparent higher number of presentations and a higher percentage of those leading to admission in UHL compared to other hospitals, it said.
HSE CEO Bernard Gloster said that “accountability is and will be pursued fairly and appropriately in a confidential process”.
The HSE said it is “conscious of the criticism” that the report does not make “adverse findings in relation to any individuals”.
Gloster said the “question of accountability has to be addressed by me as the employer and it can’t be addressed by Mr. Justice Clark”.
He said any attempt to do so would be outside of the employee’s contractual rights and “would likely be struck down by the courts in any challenge”.
Gloster also said an individual would have “no chance of a fair disciplinary process” had the report “made an adverse finding against an individual”.
However, Gloster said the report has “given the pathway to that accountability process, and that accountability process has commenced”.
While he said this is “private to those individuals,” he added that the accountability process has commenced very significantly so in respect of several people” and that this would not have been possible without the report by Clark.
Health Minister Stephen Donnelly said work is underway in the HSE to implement the report’s 17 recommendations.
He noted that the report stated that “unclear protocols, ad hoc systems, poor internal communication and a failure to deploy the escalation protocol” all contributed to Aoife’s death.
Donnelly added that HIQA is currently undertaking a review into whether there should be a second ED in the Midwest region.
Meanwhile, the Irish Hospital Consultants Association described the report as “troubling and telling” and noted that the ED was “grossly overcrowded” and at over three times its maximum patient capacity when Aoife was admitted.
The Irish Nurses and Midwives Organisation said the report must be the “catalyst for meaningful and lasting change in respect of overcrowding”.
“The Minister for Health and CEO of the HSE must now make this a priority,” said INMO General Secretary Phil Ní Sheaghdha.
Elsewhere, Sinn Féin’s health spokesperson David Cullinane called for all of the report’s recommendations to be “urgently implemented in full” while the Social Democrats’ health spokesperson Róisín Shortall said that “clear that political accountability, for chronic overcrowding and a lack of capacity at UHL, is required”.
-With additional reporting from Diarmuid Pepper
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