An inquiry into a 16-year-old girl’s death at Limerick’s University Hospital (UHL) established that her demise occurred under conditions that, according to medical evidence, were “almost certainly preventable”. The teenager, Aoife Johnston from Shannon, County Clare, succumbed to meningitis on December 19, 2022, in UHL, after she had been neglected without antibiotics, a “crucial” intervention for her survival, for over 13 hours.
The much-anticipated study by ex-chief Justice Frank Clarke about Ms Johnston’s death, released on Friday, concluded that the hospital’s casualty ward was “significantly under-staffed” and employed an “insufficient” and “random” method to highlight and escalate distressed symptoms of patients at the period.
Moreover, the turmoil at the provincial hospital was “indisputably worse than it ought to have been” when she was hospitalised, due to the absence of operating decongestion protocols – generated to alleviate overcrowding.
Clarke’s investigation shows that Ms Johnston was stratified as a category two patient, indicating she should have received medical attention within 10 minutes. Considering the quantity of patients who were stratified in category two during that time and the number of doctors on duty, Clarke stated that it wasn’t realistic that category two patients could be attended to within anything close to 10 minutes.
Nurses and physicians in the area where Ms Johnston was under care at UHL apparently had no knowledge about her sepsis risk. There was a more than 13-hour gap from her attendance at the hospital to treatment, notwithstanding the fact that she was inspected by a GP who conjectured the likelihood of sepsis and a nurse recognising her risk.
The retired judge asserted that the national healthcare guidelines for sepsis dictate that treatment should be commenced within an hour. However, in his investigation, it was revealed that unlike other patients suspected of sepsis, the teenager was not directed to the “Resus” area of the hospital due to severe overcrowding. Thus, the necessary sepsis documentation, typically associated with such patients, was not available. This factor significantly influenced the ignorance of the medical staff regarding Ms Johnston’s sepsis risk, identified by a doctor and nurse.
Staffing was also highlighted as an issue by Mr. Clarke, in particular, a shortage of five nurses and one doctor on the night Ms Johnston was admitted. Irrefutable capacity issues were identified. After the closure of other Emergency Departments(EDs) in the midwest in 2009, a heavy load of emergency patients was redirected towards UHL situated in Dooradoyle.
According to a report from 2008, referred to as the Horwath report, the shut down of other EDs was not to be initiated until Dooradoyle’s capacity was enhanced. Despite this, Mr. Clarke stated that even after 15 years, Dooradoyle’s capacity was significantly lesser than the recommendation set by the Horwath Report.
Despite the revelations, the report didn’t place blame on any particular individual and failed to settle certain disputes, causing disappointment for the family of Ms Johnston. They have been insistent on the immediate, unredacted publication of the report into their daughter’s death. As of now, the published report has omitted the names of the medical professionals involved. An inquest held earlier this year attributed Ms Johnston’s untimely demise to medical misadventure.
A secondary report pertaining to UHL was published on the same day. This report, created by Grace Rothwell’s support team, tasked by the HSE and the Department of Health, investigated the overcrowding issue in the Midwest region. This nine-page Rothwell report recommended that the UHL needs to implement “resets” to deal with the emergency care demand and postpone scheduled care to provide adequate beds for those in critical need.
The advice put forth was adopted by the hospital group at the start of the summer, necessitated by the surging number of patients lying on stretchers awaiting treatment. Consequently, planned care was delayed for a fortnight before it gradually resumed.
Bernard Gloster, the HSE’s chief executive, acknowledged Mr Clarke’s report, stating it “provided guidance for both reflection and accountability”. He further assured, “this accountability will be pursued in a just, appropriate manner while maintaining confidentiality”.
In addition, a separate request has been made by the Department of Health to the Health Information and Quality Authority to determine the necessity of a second Emergency Department in the Midwest, in response to the escalating demand.