THE HSE CEO has said the report into Aoife Johnston’s death shows that a “number of steps could and should have taken place which might have led to a more benign result”.
Bernard Gloster added that “accountability will be pursued” and that this process has “commenced very significantly so in respect of several people”.
The HSE today published the report from the independent investigation by retired judge Frank Clarke into 16-year-old Aoife Johnston’s death at University Hospital Limerick on 19 December, 2022.
Speaking to reporters this afternoon, Gloster said there is “no report will undo the harm that was caused to Aoife’s family and the failure that led to the catastrophic consequences for Aoife and her family”.
“We failed her, and for that we are, and have to remain, truly sorry,” said Gloster.
The report states that a failure to implement a decongestion protocol in the Emergency Department at University Hospital Limerick made “what would have been a bad situation much worse”.
Aoife presented to the hospital’s ED at 5.39pm on Saturday, 17 December 2022, and had a letter of referral from an out of hours GP querying sepsis.
However, the appropriate sepsis medication was not administered until between 7.15am and 7.20am the following morning.
This was a 13-and-a-half hour gap, when the National Protocol on sepsis suggests that treatment should take place within an hour.
The report notes that there was an “exceptional level of overcrowding in the ED” on 17 and 18 December.
The report questioned why decongestion protocols to reduce overcrowding were not implemented and remarked that a “failure to follow the decongestion protocol seems to be a material factor in any overall assessment”.
However, the report notes that there is a “conflict of evidence” as to why the decongestion protocol wasn’t implemented and Gloster said this conflict is “essential” to understanding what went wrong.
The report outlines a “significant conflict of evidence” as to whether an instruction was given that the trolleys with admitted patients should be placed on wards to ease pressure on the ED.
The conflict of evidence remained despite the fact that everyone who gave evidence was provided with “reasonable opportunity to ensure their side of the case was fully and fairly set out”.
The report said that while the number of patients in the ED meant “significant overcrowding” was inevitable, it added that a failure to implement the decongestion protocol made the overcrowding “more severe than it should have been”.
Meanwhile, there was a shortage of five nurses and one doctor in the ED on the night Aoife was admitted and the night nurse was not informed that there was a concern Aoife has sepsis.
Such “lack of clarity” was highlighted in the report, which added that while decisions had been taken at Senior Management level, managers on the ground were not always as clear as to precisely what had been decided”.
It was this lack of clarity that contributed to delays in Aoife being treated.
It wasn’t until 6am the morning after she was admitted that she was prescribed a sepsis bundle of medication, despite presenting as and being triaged as a possible sepsis case.
However, it took over an hour and 15 minutes for the medication to actually be administered after being prescribed.
A patient at risk of sepsis should receive this medication within an hour of being triaged, and the report said it “clearly makes no sense” that 11 hours after being triaged, there was a further wait of more than an hour for the drugs to actually be administered.
The report said an “ad-hoc system” that “just did not work” was in place regarding Aoife.
Gloster described the report as “comprehensive” and that it is a “pathway to accountability”.
Meanwhile, there are 17 recommendations in the report, including that patients should not be waiting over an hour for medication after it is prescribed and that communication systems should be reviewed.
Gloster said he accepts all of the recommendations and that work is underway in relation to some of them.
Gloster said he has asked the Chief Clinical Officer to review the sepsis policy protocol and to “formulate what is the best guidance in those circumstances”.
The HSE CEO also 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”.
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.
Gloster added that he is available to meet with Johnston’s family to “discuss concerns about the report”.
To embed this post, copy the code below on your site
have your say