A friend of mine lives in Ennis where the A&E unit in the local hospital was closed down in 2009 despite huge opposition from people in Clare who understood exactly what it would mean if services were moved out of the county and into a hospital already servicing a busy city.
She said that it has become a sort of running joke – the kind that isn’t really funny – to say that no-one should attend the Emergency Department in Limerick unless they had absolutely no other option whatsoever. “You’d be taking your life in your hands”, was the general comment, usually accompanied by dark tales of horrendous days spent on trollies, general chaos and upset, and a sense of overcrowding spiralling out of control.
But the situation stopped being a joke a long time ago. And the shocking, appalling evidence heard last week at inquest into the death of 16-year-old Aoife Johnston in the hospital gave a terrifying insight into chaos in Limerick’s A&E. It was also a stark reminder of the utter foolishness of closing down smaller facilities in a rush to centralise care against warnings given at the time that deaths might occur.
In the run-up to the closure of the emergency department in the hospital in Ennis in 2009, the concerns of the people actually living in the county and using the hospital’s emergency services were, as ever, dismissed by the policymakers and managerial types who promised a new “centre of excellence” (remember that buzzword) in Limerick instead.
The A&E in Nenagh was closed around the same time. People in south Tipp requiring treatment would need to join the queue in what was then the Mid Western Regional Hospital – just like those living in places like Kilkee, in West Clare, who would now have to travel an hour and eighteen minutes to get to Limerick.
At one stage, some 20,000 people protested the closure of the A&E in a monster meeting in Ennis. It was the biggest crowd seen in the town square since Dev’s election in 1917, the organisers said. A cardiologist warned that medical experts had “critical concerns” about diagnoses of life-threatening conditions. Independent TD Jerry Crowley, a medical doctor, told the rally: “People will die. There is no question whatsoever”.
Doctors wanted to know what support the HSE would provide for the out-of-hours service, Shannondoc, when the A&E closed. Then chairman of the Clare branch of the Irish College of General Practitioners, Dr Michael Harty, said that without additional supports the service would be unable to cope with the increased workload. “The HSE is proceeding with the reconfiguration without any prior agreement with the GPs,” he said.
The Irish Medical Organisation secretary for Clare, Dr Michael Kelleher, added that he had “serious concerns that what is being proposed is unsafe.” The Irish Times reported that “GPs feared that the reconfiguration of services was “far more to do with cutbacks than an improvement in services”.”
All those concerns were dismissed by the powers that be.
The clinical director of the Mid Western Hospitals Reconfiguration Project Team, consultant surgeon Paul Burke said: “The objective of the changes is to provide high-quality and safe services closer to the patient’s home where possible, while at the same time ensuring that those who require complex care can get access to it as quickly and as safely as possible.”
HSE staff wanted the patient to “receive the right care in the right place at the right time”.
The HSE review had made its recommendation and that was all that mattered apparently, as is increasingly the case in our curiously unrepresentative democracy on a great many issues. So over the past 15 years, the HSE have stood by their decision even as the supposed “centre of excellence” in Limerick became a national scandal.
The Irish Nurses and Midwives’ Organisation (INMO) listed University Hospital Limerick (UHL) as the most overcrowded hospital in Ireland last year – and it consistently features strongly on that most miserable of metrics, the trolley watch recorded by the nurses’ body.
(Isn’t it amazing, by the way, that these figures are collated, not by the HSE but by an organisation representing nursing. Why is that the case? The Irish state fails to keep sufficient statistics in a great many areas, which curiously often seem to correspond to the areas where it is failing and failing dismally.)
HIQA reports have persistently pointed to serious overcrowding and bed shortages – with a 2022 inspection concluding that the Emergency Department in UHL was trying to deal with twice as many patients as it was designed to deal with. That’s a key point: closing down regional hospitals and massively expanding the catchment area for any hospitals is going to lead to the remaining hospital being swamped.
The government opened what was described as a “state of the art Emergency Department” in UHL in 2017, but it was built to cater for a maximum of 190 patients, and those numbers are consistently exceeded, with patients numbers often rising above 250 patients on a given day. The Limerick hospital is serving a population of some 420,000 people across Limerick, Clare, and North Tipperary. The problem is not going to go away.
In February of this year, UHL again set a new record for overcrowding with the INMO saying the conditions were “unacceptable and dangerous for patients” and that patients “no matter what their condition is, are placed on trolleys in all available spaces, on public corridors of the hospital, on ward corridors and in the emergency department leading to a completely congested hospital with no patient movement to access an in-patient bed”.
“The levels of persistent overcrowding are having a very damaging impact on the morale of the nursing staff in the hospital who are trying their best to provide safe patient care in an extremely trying environment.”
The INMO made that statement 14 months after young Aoife Johnston from Shannon from Co Clare died in UHL in a case that underscored the shocking, devastating, deadly effects of the chaos and dysfunction in UHL and in any hospital where capacity is persistently overwhelmed.
The appalling circumstances in which the sixteen year old girl died, were summed up by her heartbroken mother who said: “Aoife had a horrible death and she suffered all night. People need to know that.”
Ms Johnston, who had been sent to the hospital by a doctor on the evening of December 17th, 2022, because of suspected sepsis, should have been by a doctor within 10-15 minutes, the inquest into her harrowing death heard. Instead, 15 long hours passed before she was given the necessary antibiotics, while she “violently” vomited green liquid, her temperature rose and she was “screaming in pain”.
Her increasingly distressed parents, who had been forced to push two chairs together to make a bed for her as there was no trolley, begged staff to help during that long, terrible wait as their daughter – “beautiful inside and out” – deteriorated before their eyes.
"I never got to say goodbye to her, when I got that call she was already gone"
– Aoife Johnston's sister Megan speaks after inquest verdict pic.twitter.com/3ly7NlEaMB
— TheJournal.ie (@thejournal_ie) April 25, 2024
Dr Jim Gray, an emergency medicine consultant at the hospital described the emergency department in Limerick which had failed Aoife Johnston as a “death trap” – which he said was “consistently the worst in the country”. He said Ms Johnston received care without dignity or privacy and that such conditions were “an abuse of human rights.”
Clinical Nurse Manager Katherine Skelly, who was on duty on the night that Ms Johnston came in said that on that weekend what she observed “was akin to a war zone”.
Dr Patrick Stapleton, a consultant microbiologist also told the inquest that Ms Johnston’s sepsis could have been treated with a range of antibiotics – and that it was “highly likely” that if the correct antibiotics had been administered in time her life could have been saved – that the outcome “would have been different and optimal”.
Her entirely preventable death, and the enormous suffering of Aoife Johnston’s family must be a catalyst for change. Local campaigners, who also point to the tragic death of Eve Cleary from Limerick, have demanded that the A&E departments in Ennis and Nenagh be re-opened, precisely because they believe that the capacity issue at UHL is leading to such terrible outcomes.
Some TDs and Senators are now supporting that call, but Health Minister, Stephen Donnelly, has rejected the suggestion, insisting that increasing the number of consultants in UHL is the better option, while the HSE also remains opposed.
Yet the stubborn issue of capacity remains. How can any hospital with an emergency department build to take a maximum of 190 people continually care for an excess of those numbers? And the increased catchment area for any hospital surely leads to almost insurmountable problems in terms of overcrowding.
Dr Jerry Crowley was right. People have died, and medical staff are in despair. The promised “centre of excellence” has become a “death trap”. This situation cannot continue.