Health Service Executive chief executive Bernard Gloster has said there continues to be a “risk” to life at University Hospital Limerick (UHL) following the death of 16-year-old Aoife Johnston in December 2022 due to failures in timely treatment.
An investigation into the death of Ms Johnston found that doctors and nurses at the emergency department (ED) were unaware of her sepsis risk, and because of overcrowding she was sent to the wrong section of the ED where sepsis forms were not kept or filled out.
The report, carried out by former chief justice Frank Clarke, also outlined what he described as serious conflicts of evidence among staff about patient flow protocols to alleviate overcrowding and how they did not operate on the night of her admission to the ED. This in turn meant the overcrowding was more severe than it should have been.
The report says the investigation into her tragic death arose in circumstances which, on the basis of all the medical evidence given to him, were almost certainly avoidable.
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When asked if UHL’s ED was safer now, Mr Gloster, speaking on RTÉ Radio 1′s This Week programme, said: “Safer and that’s what I say in every part of the health service.”
When it was pointed out that Mr Justice Clarke said this type of death could happen again and there was a risk of reoccurrence, Mr Gloster said: “I think there is that risk there but I think the risk is less. I think the risk is mitigated and I think it is increasingly mitigated. However, that said, I have concerns arising out of Frank Clarke’s report, and indeed of my support team I sent to the hospital in May, around the systems in which the emergency department operates as part of the overall hospital.
“I am satisfied every step is being taken at this point in time to make it safer and safer is what I continue to pursue.”
He confirmed that operating structures within the hospital will be changing from Monday of next week, September 30th.
He revealed that currently there are four people on administrative leave from the particular roles that they have but there are a number beyond that also that are subject to disciplinary investigation – a total of six people.
“I have said to you there’s already a significant impact on people discharging their roles at the current time without findings being made against them and that’s appropriate in this context,” Mr Gloster said.
Once all disciplinary procedures have been completed he will be able to confirm if there are any findings against them, but he will not be able to confirm who those people are.
“That’s not lawful or appropriate,” he said, adding that the disciplinary process would take a different amount of time in respect of each individual as they can be “lengthy and complex”.
Damien Tansey, the solicitor acting on behalf of the Johnston family, claimed on RTÉ's Drivetime programme last week that they were given the impression by Mr Gloster that Mr Justice Clarke would be able to make adverse findings. However, Mr Gloster said: “This was not my intention to do so.”
According to Mr Tansey when speaking on RTÉ the Johnston family wants another inquiry, a wider statutory inquiry which could go deeper and which could make adverse findings or findings of fact. Mr Gloster said he did not think that would be needed but if it were be found to be he would consent.
An implementation plan has been put in place for each of Mr Justice Clarke’s 17 recommendations, Mr Gloster confirmed.
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