The report by retired Judge Frank Clarke highlights a catalogue of failures in the care of the teenager at the hospital in December 2022 after she spent more than 13 hours on a trolley with suspected sepsis in the emergency department.
The report warns that “unless and until” that problem of lack of beds is addressed it seems likely, despite improvements in systems in the last two years that “unfortunately a risk of reoccurrence will inevitably be present.”
It said the death was almost certainly “avoidable”.
The inquiry highlights the gross overcrowding on the night she presented with 168 patients on trolleys.
The death of Aoife Johnston
Among the failings is the length of time it took from Aoife being prescribed with the sepsis bundle at approximately 6am on the morning of the 18th, to it actually being administered, which occurred between 7:15am and 7:20am.
“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.”
Nurses and doctors were not aware of her sepsis risk.
The report found that unllike most patients who are considered to be risk of sepsis, Aoife was not brought to the Resus area after triage because it was already grossly overcrowded.
“Instead she was brought to Zone A in the Emergency Department. That of itself did not cause any problems. 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.”
There are conflicts in the evidence about the manner in which Aoife’s worsening condition led to requests to doctors to see her more quickly than her place in the queue of patients awaiting being seen should have determined.
“What is, however, clear on the evidence, is that both Aoife’s parents, many other patients awaiting to be seen in the emergency department .”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. A number of senior staff are facing disciplinary action.
Commenting on the report HSE chief Bernard Gloster said: “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.
It said that 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.
