Report into death of girl (16) warns another tragedy still possible at Limerick hospital
Family solicitor Damien Tansey said they had to endure another agonising seven-month wait for the investigation report of retired judge Frank Clarke.
The damning report, issued yesterday, revealed a catalogue of failings in the 16-year-old’s care in December 2022 and warned that a lack of beds leaves patients at risk of another fatal tragedy.
“A previous inquiry was already completed and there was also the inquest into Aoife’s death. They are puzzled that it took another inquiry before disciplinary proceedings could be acted on,” Mr Tansey said.
Three staff are facing disciplinary proceedings following the report, and it may also extend to a number of other senior staff.
Mr Tansey was speaking after Judge Clarke’s report unveiled more stark detail about the failings in the care of the teenager, from Shannon, Co Clare.
Judge Clarke warned that ‘unless and until’ the problem of a lack of beds in the hospital is addressed, a ‘risk of reoccurrence will inevitably be present’
Aoife died of meningitis-related sepsis on December 19, 2022 after waiting on a trolley for more than 13 hours in the hospital’s emergency department.
For the Johnston family, there is the loss of a daughter. For other patients, there is the chilling warning by Judge Clarke that “unless and until” the problem of a lack of beds in the hospital is addressed, a “risk of reoccurrence will inevitably be present”.
This is despite improvements at the hospital since Aoife’s death to mitigate risk.
The death of Aoife Johnston
Additional acute beds will not ready until early next year, which will leave the hospital struggling with another tide of patients during the winter surge in flu and other respiratory illnesses.
The inquiry highlighted the gross overcrowding on the night Aoife presented, with 168 patients on trolleys.
Among the failings was the length of time it took between Aoife being prescribed with the sepsis bundle, at about 6am on December 18, and it actually being administered, which happened between 7.15am and 7.20am.
She had presented to the emergency department at 5.39pm on December 17 with a GP’s letter saying there was a possibility of sepsis.
“In circumstances where the relevant protocol suggests that a patient should be treated within an hour of being triaged as being at risk of sepsis, it clearly makes no sense if, even after the patient was belatedly seen by a doctor, it took more than that hour for the drugs to be actually administered,” the report said.
Nurses and doctors were not aware of her sepsis risk. The report found that unlike most patients who are considered to be at risk of sepsis, Aoife was not taken to the resus area – where the most seriously ill patients are dealt with – after triage, because it was already grossly overcrowded.
“Instead, she was brought to Zone A in the emergency department,” the report said. “However, the appropriate sepsis forms that normally accompany a patient who is suspected of having sepsis were, at the time, only kept in the resus area. As Aoife bypassed the resus area, no form was filled out in her case.
“This undoubtedly contributed to the fact that it appears that none of the nurses or doctors who were involved in dealing with patients in Zone A were aware that Aoife had been identified both by a GP and a nurse as being at risk of sepsis.”
A nurse became increasingly concerned about Aoife’s condition and expressed those concerns as best they could.
The report does not name any of the staff involved.
Health Minister Stephen Donnelly said ‘work is under way’ to implement the recommendations. Photo: PA
Judge Clarke said it is an “undoubted fact” that the number of patients presenting at the emergency department was “extremely large”.
He added that there were five fewer than the full roster of nurses and one doctor down on the full roster.
That meant that while all patients in as severe a condition as Aoife should have been seen in less than 10 minutes, it would appear that it would have taken more than 10 hours to see all “category two patients”.
He said a “very ad hoc system” was operating, in which nurses could escalate patients up the list if they were concerned about their deteriorating condition.
“The evidence suggests that the system, if it can be called that, was inadequate to deal with a very difficult situation where the large number of patients and limited number of nurses and doctors made the monitoring of patients with potentially deteriorating conditions much more difficult,” the report said.
Judge Clarke said one specific factor that relates to the events of December 17 and 18, 2022, was the failure to implement the decongestion protocol overnight .
There can be no doubt but that this made what would inevitably have been a bad situation much worse and thus materially exacerbated the difficult conditions in which staff were required to work, the report said.
Judge Clarke said “the evidence strongly suggests that, at least by the middle of December 2022, there was no basis on which decongestion should not have been operated when the number of patients in emergency department exceeded 23”.
‘We failed Aoife and our failure has resulted in the most catastrophic consequences for her and her family’
The report makes a series of recommendations and says other hospitals enduring the “eternal winter” that is emergency overcrowding and an inevitable escalation in the coming months will lead to more patient hardship.
HSE chief Bernard Gloster said: “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.”
He outlined a series of measures to reduce the pressure on the hospital and said staff are being recruited to work in the new beds to open in the coming months.
Health Minister Stephen Donnelly also expressed his sympathies with Aoife’s family and pointed to the review being carried out by the Health Information and Quality Authority (Hiqa) to examine if another emergency department is need for the region. It is expected that the cancellation of planned surgeries will need to be called on at various times over the winter to relieve congestion.
Mr Donnelly said: “Work is now under way in the HSE to implement Mr Clarke’s recommendations and to build on the improvements already made at UHL since 2022, as acknowledged in Mr Clarke’s report.
“The report identifies a number of factors that contributed to delayed treatment and Aoife’s death, including unclear protocols, ad hoc systems, poor internal communication and a failure to deploy the escalation protocol.”
A separate report was also published yesterday following an on-site review by a small team, which included retired emergency consultant Fergal Hickey.
It highlighted the need to improve patient flow and speed up discharges.
They said the emergency department “would undoubtedly function very well if it were permitted to do so”.
The Irish Hospital Consultants Association said: “The normalisation of the abnormal pressures is also addressed by Judge Clarke when he states, ‘There may be an unconscious acceptance of a level of challenge as normal, or at least, reasonably normal, when, in truth, the situation may be well beyond what might be objectively considered to fall within normal bounds’.
“He acknowledges a review of acute hospital services in the Midwest undertaken 15 years ago. The recommendations in that review were not followed.
“Meanwhile, the growing population in the Midwest region continues to strain an already overburdened emergency department. Transparency, collaboration and swift action are essential to restoring trust in and within UHL.”
Sinn Féin TD David Cullinane said: “Aoife was placed in the wrong part of the hospital because the resuscitation area, where she should have been, ‘was already grossly overcrowded’.
“It seems that management did not have a back-up plan for this eventuality, and that a reliance on a pen-and-paper system in the middle of a crisis meant that staff could not be aware of or properly respond to Aoife’s condition.
“The lack of a back-up plan for the resuscitation area in particular, and the single-point-of-failure that is UHL ED as a whole, mean that there were no services available to support UHL during a crisis.”
