A report into the “avoidable” death of a 16-year-old girl at University Hospital Limerick in 2022 has warned that it could happen again unless bed shortages and overcrowding in its emergency department are resolved.
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.
A report into her death by former chief justice Frank Clarke, published on Friday, found she died in circumstances that, on the basis of the medical evidence, “were almost certainly avoidable”.
The retired judge described the emergency department (ED) as “grossly overcrowded”, said the hospital was “significantly understaffed” and had an “inadequate” and “ad hoc” system to escalate concerns about patients’ conditions deteriorating at the time.
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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.
Mr Clarke added that “unless and until” the shortage of beds is addressed it seems likely 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.
However, due to the number of doctors available and the number of category two patients, “it would appear that it would have taken over 10 hours (as opposed to 10 minutes) to see all category two patients”.
Doctors and nurses in the ED were “unaware” of Ms Johnston’s sepsis risk, the independent report found, as she was brought to an area of the ED where sepsis forms were typically not kept.
When she was prescribed with antibiotics to treat sepsis, it took more than an hour for them to be administered to her.
“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,” the report found.
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 that “some 15 years later, the capacity of Dooradoyle is significantly below that recommended by the Horwath report”.
In a statement, Minister for Health Stephen Donnelly said the report “highlights the particularly severe pressures that night in the emergency department”.
“Hiqa has been asked to lead a review into urgent and emergency care capacity in the midwest region, including to determine whether a second emergency department is required,” he added.
Phil Ní Sheaghdha, general secretary of the Irish Nurses and Midwives Organisation (INMO), said: “It could not be clearer that the State’s inpatient bed capacity must be improved in tandem with safe levels of nurses and doctors to deliver care and treatment.”
Bernard Gloster, chief executive of the HSE, said “we failed Aoife and our failure has resulted in the most catastrophic consequences for her and her family”.
“It [the 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.”
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