An investigation into the death of a 16-year-old girl at University Hospital Limerick (UHL) has found she died in circumstances which, on the basis of the medical evidence, “were almost certainly avoidable”.
Aoife Johnston, from Shannon in Co Clare, died of meningitis on December 19th, 2022, at UHL, after she was left for more than 13 hours without antibiotics, a “vital” treatment to help save her life.
The long-awaited report by former chief Justice Frank Clarke into Ms Johnston’s death, published on Friday, found the hospital’s emergency department (ED) was “significantly understaffed” and had an “inadequate” and “ad hoc” system to escalate concerns about patients’ conditions deteriorating at the time.
Furthermore, overcrowding at the midwest hospital was “undoubtedly more severe than it should have been” when the Co Clare teenager was admitted as a result of decongestion protocols – designed to reduce overcrowding – not being operated.
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The retired judge sounded a general warning about capacity issues at UHL in his report, saying that the risks he identified to patients “will not be further minimised without addressing the fundamental problem of overcrowding” in the hospital’s ED.
He said that “unless and until” the shortage of beds is addressed it seems likely that the ED will “unfortunately but regularly be under pressure” and that despite improvements since 2022, “a risk of reoccurrence will inevitably be present”.
According to the Clarke report, Ms Johnston was triaged as a category two patient, meaning she should have been seen by a treating clinician in 10 minutes.
“Having regard to the number of patients who were triaged in category two on the occasion in question and the number of doctors available, there was no reality to patients who were categorised in category two being seen by a clinician within anything remotely resembling that time frame,” he said.
“Indeed, it would appear that it would have taken over 10 hours (as opposed to 10 minutes) to see all category two patients.”
The Clarke report found that nurses and doctors at UHL in the area where Mr Johnston was being treated were “unaware” of the risk of sepsis facing her.
He found there was a thirteen and a half hour gap between her presentation at the hospital and treatment, despite being seen by a GP who queried the possibility of sepsis and a nurse identifying the risk of sepsis to her.
The national protocol on sepsis followed by hospitals “suggests that treatment should take place within one hour”, the retired judge said.
His report said that unlike most patients considered at risk of sepsis, the teenager was not brought to the “Resus” area of the hospital after triage because it was “already grossly overcrowded” and where the “appropriate sepsis forms” that normally accompany a patient suspected of having were kept.
This “undoubtedly contributed” to the fact that it appeared that none of the nurses or doctors involved in dealing with patients in the other area were aware that Ms Johnston had been identified both by a GP and a nurse as being at risk of sepsis.
Staffing was another issue, with Mr Clarke noting a shortfall of five nurses on the night in question, as well as one doctor.
Mr Clarke highlighted capacity concerns. Other EDs in the midwest were closed in 2009, resulting in all serious emergency patients being directed towards UHL in Dooradoyle.
A 2008 report, known as the Horwath report, noted that the closure of the other EDs should not occur until the capacity of Dooradoyle was increased.
However, Mr Clarke said “some 15 years later, the capacity of Dooradoyle is significantly below that recommended by the Horwath Report”.
The report did not make any adverse findings against any individuals, nor did it resolve a number of conflicts, a point of “disappointment” for the Johnston family.
Ms Johnston’s family have been demanding the report on her death be published immediately and without redactions. The published report has redacted the names of clinical staff involved.
An inquest into Ms Johnston’s death earlier this year recorded a verdict of medical misadventure.
A second report on UHL was also published on Friday. It contained findings from a support team who was tasked by the HSE and the Department of Health to look at the issue of overcrowding in the Midwest region, led by Grace Rothwell.
In the Rothwell report, which is nine pages long, the support team advised the HSE that UHL will need “resets” to cope with demand for emergency care, during which scheduled care will be postponed to ensure there are sufficient beds for those most in need.
The hospital group utilised this recommendation earlier in the summer, due to high numbers of patients waiting on trolleys. Scheduled care was postponed for two weeks, before it gradually began to return.
Bernard Gloster, chief executive of the HSE, said Mr Clarke’s report has “given us a pathway to both learning and accountability”.
“That accountability is and will be pursued fairly and appropriately in a confidential process,” he added.
The Department of Health has also separately requested the Health Information and Quality Authority establish whether there is a need for a second ED in the Midwest, to cope with demand.
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