Warnings have been sounded about the potential for further preventable deaths at the University Hospital Limerick (UHL) unless issues of overflowing emergency departments and insufficient beds are properly addressed. These concerns followed a report into the tragic passing of a 16-year-old girl, Aoife Johnston, of Shannon, Co Clare, who sadly lost her life to meningitis on December 19, 2022, at UHL. She had to wait over 13 hours without receiving antibiotics, a crucial element of her life-saving treatment.
The report into her death, released on Friday and led by retired chief justice Frank Clarke, concluded that her death occurred under circumstances that the medical evidence strongly suggests were totally preventable. Mr Clarke criticised the hospital for being “grossly overcrowded”, “gravely understaffed”, and operating what he described as an “insufficient” and “temporary” system for escalating concern around the worsening conditions of patients.
Mr Clarke pointed out that patient risk would inevitability remain unless overcrowding issues in the emergency department were resolved. He further explained that the shortage of beds needs to be immediately addressed to alleviate the persisting pressure on the emergency department and to significantly reduce the risk of reoccurrence, despite the improvements made since 2022.
The Clarke report revealed that Aoife Johnston was designated a category two patient, implying she should have been attended to by a clinician within 10 minutes. However, the high number of patients in the same category and limited number of doctors meant it would have taken more than 10 hours, instead of the standard 10 minutes, to attend to all category two patients.
Disturbingly, the report uncovered that medical staff in the ED were oblivious of Ms Johnston’s risk of sepsis. She was positioned in an area of the emergency department where sepsis forms were not typically maintained.
After being diagnosed with sepsis, a delay of over an hour occurred before antibiotics were administered to her. According to the ratified protocol, patients identified as at risk of sepsis should receive treatment within an hour from their triage. The report criticized the actual implementation that saw the patient receive the required medication after the stipulated one hour, even though the patient had already been attended by a doctor.
Capacity issues were brought to light by Mr Clarke. In 2009, other emergency departments (EDs) between the midwest region were closed, which led to serious emergency patients being redirected to the UHL in Dooradoyle. Following the Horwath report in 2008, it was stated that shutting down other EDs should not be an option unless the capacity of Dooradoyle is expanded.
Mr Clarke pointed out that “15 years down the line, Dooradoyle’s capacity is still considerably less than the Horwath report’s recommendation”.
Stephen Donnelly, the Health Minister, conveyed that the report “underlines the tremendous pressure that the emergency department experienced that evening”.
He further announced, “Hiqa has been commissioned to spearhead a review of the urgent and emergency care capacity in the midwest region, which includes a consideration for the need of a second emergency department”.
Phil Ní Sheaghdha, the INMO’s general secretary, inferred: “It is blatantly evident that, in sync with the safe nurse and doctors’ levels, improvement of the state’s inpatient bed capacity is also mandatory to provide proper care and treatment.”
Reflecting on the incident, Bernard Gloster, HSE’s chief executive, admitted, “we let Aoife down and our shortcoming has led to dire repercussions for her and her family”.
He emphasised, “this report provides us both an opportunity to learn and to be held accountable. This responsibility is and will be pursued thoroughly and aptly in a confidential procedure.”