A previously unreleased review into the death of teenager Aoife Johnston, which found that overcrowding in University Hospital Limerick (UHL) was endemic and that there is little apparent understanding of the risks and inefficiencies caused to patient care by a crowded environment in its system, will form part of a new independent investigation into her case.
The new investigation will be headed up by former chief justice Frank Clarke, and is expected to take some 8 weeks.
Ms Johnston’s family said today through their legal team that they had not been consulted on the terms of reference for the investigation – and while some media had access to the previous review of the case, the family did not.
That damning review – a Systems Analysis Review – found that there are insufficient Emergency Department (ED) nursing staff to provide adequate monitoring and care to the patients in UHL, and that there are insufficient Emergency Medicine doctors to care for the numbers and acuity of patients presenting in the timescale expected by the Triage system, the hospital and the community.
16-year-old Aoife Johnston died from bacterial meningitis in December 2022, two days after she first presented at the A&E at University Hospital Limerick. The sixth year student had travelled to the hospital with her parents from her home in Shannon, Co. Clare, expecting that they would be treated urgently.
Earlier this month, the HSE confirmed that there were “serious failings” surrounding her care following the outcome of an external review.
“We have apologised to them for the serious failings in the care we provided to their daughter which have been identified in the review,” the statement said.
251 patients were attending the hospital’s emergency department when Ms Johnston’s family arrived on 17th December – one of its busiest days ever.
It was reported that an emergency department consultant who was called to come and support the staff declined to attend the hospital, saying it was not the function of an A&E department to “sort out overcrowding.”
The teenager and her family remained waiting through the night to be seen, while the hospital’s “full-capacity” protocol was never kicked in on the night of Saturday 17th December, despite the surge in patients.
According to the review into her care, Aoife Johnson’s parents made “multiple attempts to highlight her condition” – finding that her parents had done “everything possible” to care for their child during the day and night spent in UHL.
While she eventually received a medical review at 6am, and received “appropriate treatment” according to the review, this was done 12 hours too late.
Later that morning, the schoolgirl was admitted to intensive care, and she died the next day, Monday 19th December.
The teenager had bacterial meningitis, and she was classed as a category 2 patient when she was seen by staff, meaning that she required urgent treatment and should have been seen within 15 minutes.
In her triage, possible sepsis was noted, an infection which can lead to septic shock, organ failure and death, if not treated urgently.
According to the review into Ms Johnson’s care, she should have been administered with a sepsis bundle – a three hour bundle of treatments to be completed within 3 hours of a diagnosis, which includes taking blood samples, and administering antibiotics and an intravenous fluid bolus for hypertension. However, the potentially life-saving treatment was not administered in time, according to the review.
The independent investigation will now probe not just the care but also how the hospital is run after the damning findings of the internal review of the tragedy were confirmed by the HSE.
The review also found that staff had not yet been appointed to specifically funded jobs to facilitate the admittance of patients to the ED.
“The ‘boarding’ of admitted patients in the ED is a planned part of patient flow in this hospital and includes specific funded jobs for staff to care for these patients, which are yet to be appointed,” it said.
“There is little apparent understanding of the risks and inefficiencies caused to patient care by a crowded environment by the Hospital System, in terms of the impact on the Emergency medicine doctors assessing, and managing patients and the nursing staff’s ability to provide safe care,” it also found.
Other findings of the SAR were:
• There is a high turnover of staff both Nursing and EM Non Consultant Hospital Doctors (NCHDs) which leads to low experience levels and low situational awareness.
• There was only 1 Clinical Nurse Facilitator to support nurse integration and education at this time.
• There is only 1 EM Consultant who is on-call for the whole weekend and, as they cannot be present all the time, this leads to them providing specific supports only. This has led to an expectation gap.
• The National Guideline No. 26: Sepsis management in Adults and Maternity was not followed on the 17th December 2022 leading to a delay in sepsis care of 12 hours.
• The escalation protocol was not adhered to on Sat 17th day or night despite numbers of patients awaiting an inpatient bed varying between 42 and 55.”
HSE chief Bernard Gloster said: “The scope of the independent investigation is to provide an evidence-based report on the circumstances surrounding the death of Aoife and the clinical and corporate governance of University Hospital Limerick which led to the conclusions set out in the previous systems analysis report.
“The judge has been asked to make any recommendations as he sees fit and to report directly to me.”