War-zone. Catastrophe. Trolley park. Strong words are often used to try to describe the conditions facing patients in the emergency department of University Hospital Limerick (UHL). Ireland’s most overcrowded hospital continues to set unwelcome records, with no solution in sight.
“There were 92 patients on trolleys one day in 2020 and we thought that was scandalous. But this April, they hit 126. Now any day with under 100 trolleys is regarded as a good day,” says Noreen Moran of the Mid-West Hospital Campaign, which wants the former emergency departments in Ennis and Nenagh hospitals reopened to take the pressure off Limerick.
“On the worst days, it is head to toe in the ED, trolleys lined up double, men and women together. There’s no dignity, no privacy; it’s a war-zone where staff are doing their best in impossible conditions.”
Limerick’s woes spill over from the emergency department (ED), and are by no means confined to it. One day last March, 15 ambulances had to queue outside the hospital due to high levels of patient overcrowding. UHL has over 40,000 outpatients waiting for an appointment, more than anywhere outside Galway and the Mater Hospital in Dublin; 16,000 have been waiting for over 18 months.
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For over a decade, the hospital has been battling repeated outbreaks of the CPE superbug. During the Covid pandemic, it was one of the first hospitals to suffer a large outbreak and continues to have more cases of hospital-acquired Covid than anywhere else. Last Sunday, 31 patients in Limerick had Covid, more than anywhere else.
There have also been tragic deaths, such as that of 18-year-old Jessica Sheedy, who died in the hospital in May 2018 after routine surgery went wrong, or 21-year-old Eve Cleary, whose death from a lung clot occurred shortly after a 17-hour spell on a trolley in the hospital in 2019.
The default explanation for the hospital’s woes is the 2009 reconfiguration of services in the region that saw the closure of the emergency departments in Ennis and Nenagh hospitals and their replacement by minor injury units that shut their doors at 8pm. That left UHL with the only 24/7 emergency department in a region with a population of more than 400,000.
“A lot of the problem is historic,” says retired Clare GP and former TD Dr Michael Harty. “Limerick is squeezed between Galway and Cork. The department views it in a poor light for access to specialised services, given it is only a few hours away from the other two cities.”
‘Disastrous’
“They closed the other EDs before Limerick’s new ED was ready to go. That was disastrous,” says Noreen Moran. “Since then, far too many people are being directed to UHL due to the downgrading of the other hospitals.”
Half of all ED patients come directly to the hospital, without having seen a GP beforehand. “If you can’t get a GP out of hours and you have a serious problem, you’re not going to take the risk of waiting until the doctor opens up for business the following morning,” she says.
[ ‘He had no privacy, no dignity’: Life and death at University Hospital LimerickOpens in new window ]
The closure of ED units in Ennis and Nenagh, taken for safety reasons, is unlikely to be reversed. Yet overcrowding in UHL’s emergency department is leading to new safety problems. In 2019, it emerged two patients had spent three weeks on a trolley in the hospital while older patients were developing pressure sores after spending days on trolleys. In one month, staff made 442 notifications of incidents and near miss incidents.
In an open letter to people in the midwest in 2019, doctors at UHL defined the hospital’s problem as “not enough doctors and nurses, not enough inpatient beds, not enough access to critical care or theatre, not enough access to diagnostics, [and] not enough stepdown facility beds and/or community services”.
A patient perspective was provided by Maria and Helena O’Dwyer earlier this year, writing of the “horror show” of their father’s 54-hour wait in ED. They talked about “a disjointed system of communication, a skewed definition of risk and the absolute abandonment of any sense of compassion” for patients. Staff’s efforts to show kindness “seem entirely quashed by layers of bureaucracy, management and rule that leave little space, and certainly no time, to worry about the dignity of patients”.
Communications at the hospital are a “complex calamity”, they said. “While patients are asked the same questions over and over again, answers to their questions are as rare as the disposable cups that you would expect to find beside water fountains in a hospital.”
UHL’s clinical director, Prof Brian Lenehan, says the hospital lacks the capacity to deal with the “staggering” number of patients attending. “We have seen unprecedented numbers of patients attending our ED day in, day out. But we don’t have the capacity to meet demand for the admitted patients.”
Before the pandemic, an average of 190 patients attended the ED; today, that figure is 240.
Investment
Limerick has had its share of investment over the past decade, with little tangible improvement. A new €24 million emergency department opened in 2017 and was touted as the solution to overcrowding. Over the pandemic, 98 new beds and 10 ICU beds have been added. A new 96-bed block is in planning but won’t be ready until late 2023.
“Whatever funding UHL has looked for, it has been provided,” says Clare Fine Gael Senator Martin Conway. “And if additional funding is requested I’m sure that would be facilitated.”
“We’re still playing catch-up even with that additional capacity, because it has been outstripped by the volume of attendance,” Lenehan says. He reckons the hospital needs another 205 beds in addition to the 530 it had.
Harty points to other factors aggravating the hospital’s woes. Limerick doesn’t have the “safety valve” of a “comprehensive” private hospital, “so everyone ends up there”.
In 2019, frustrated minister for health Simon Harris accused consultants at UHL of being too busy to treat a 95-year-old patient in the emergency department because they were doing private work upstairs. Mr Harris claimed the level of private work in the hospital was above average.
Seven of the hospital’s consultants swiftly responded by accusing the minister of “breathtaking political cowardice” for criticising doctors working in underfunded conditions.
The out-of-hours service provided by Shannondoc in Co Clare is largely staffed by locums rather than established GPs, Harty points out, leading to higher rates of referral to the emergency department.
A recent study of five Irish EDs by University of Limerick lecturer in public health Niamh Cummins found that UHL had the highest number of patients living in disadvantaged areas – one-fifth, compared to none in parts of Dublin.
This, she explained, translates into longer hospital stays and more pressure on services.
‘Goodwill disappeared’
The midwest has the highest proportion of over-75s in the population, as well as high levels of frailty and deprivation, Lenehan points out.
“Reconfiguration started the rot, though it’s not the only thing,” says one UHL staffer. “Half the operating theatres went, and people started fighting among themselves. Goodwill disappeared, experienced staff left, and you got more defensive medicine because people were afraid of making mistakes. With so many locum staff afraid to make a decision, the ED turned into a trolley park.”
Conway believes greater scrutiny is needed of the hospital’s “front-door” (admission) and “back-door” (discharge) policies.
“Patients are not being sent to stepdown to the level they should be. We’re not making use of nursing-home capacity, so people end up spending weekends in the hospital when they shouldn’t be.”
The biggest problem, he feels, is the lack of an elective hospital in the midwest. The Government intends to build new elective hospitals to carry out routine procedures in Dublin, Cork and Galway. These plans are making slow progress, so even if a fourth elective facility were approved for Limerick, it wouldn’t be built for years.
Lenehan expresses disappointment that the region with the biggest bed capacity issues doesn’t figure in the Government’s plans for elective hospitals.
Management in University of Limerick Hospital Group, which recently moved to offices 2km away from UHL, expend much energy warning staff against leaking to the media. Senior figures compile documents purporting to show how the hospital is underfunded relative to others.
“We have the second highest attendances to our ED in the country and the stock of beds, yet we have significant a shortfall in consultants and NCHDs benchmarked against other model 4 hospitals,” Lenehan says. “If people want to compare apples with apples, they need to ensure the same resources exist in each of the hospitals they are comparing.”
Low morale
The Irish Times has spoken to a number of staff who are critical of the way the hospital is run, and claim there is widespread low morale, but none is willing to go on the record.
Harty says of the hospital’s management: “There is a defensive element there, which would be more meaningful if it were more transparent”.
When Maria and Helena O’Dwyer, on the suggestion of a frustrated medic, complained on social media about the treatment of their father, the hospital posted a response within 10 minutes. The sisters provide a contact number on request but “nobody from UHL ever called or followed up”.
After years of overcrowding, the hospital is finally coming under closer scrutiny. A damning report published on Friday by the Health Information and Quality Authority on the hospital’s emergency department has intensified this.
This month, Minister for Health Stephen Donnelly promised the deployment of an “expert team” to UHL to examine the overcrowding issue. But it later emerged that this team comprises mid-ranking officials from the HSE’s special delivery unit, whose job it is to monitor throughput in all the country’s hospitals.
“What was announced is something that should be happening anyway. It’s just routine,” says Conway.
He, along with other local politicians and the Irish Nurses and Midwives Organisation, favours an independent investigation of the hospital’s problems. “We need someone from abroad, a Gabriel Scally [the doctor who led a prominent inquiry into the CervicalCheck screening programme], to review the problems. This is not a funding issue, it has been going on a long time.”
Asked whether the hospital would support an independent review, Lenehan replies: “Any help, internal or external, would be welcome, but they’ll be using the same data as we use.”
