A Limerick man whose father’s death was recorded as being due to medical misadventure at an inquest earlier this year has welcomed a second investigation into Aoife Johnston’s death at University Hospital Limerick (UHL) last December.
Mike Daly, from UHL Hospital Protest, Limerick, said that the investigation into the teenager’s death was “very welcomed.” After years of research, Mr Daly and his family sought a second inquest into the death of his father, Mike Daly Snr, which recorded a verdict of medical misadventure in March 2023 – overturning a verdict of natural causes recorded in 2012.
Mr Daly Snr died at Milford Hospice in Limerick in 2010, following an operation at UHL in 2007. Mr Daly, who said earlier this year that “we finally got justice for my dad” has been heavily involved with the MidWest Hospital group, and has organised a number of well-attended protests highlighting poor conditions and overcrowding at UHL.
In January last year, one month after the death of Clare teenager Aoife Johnston, 11,000 turned up in Limerick City to join a protest organised by Mr Daly, after record trolley figures were recorded at the hospital. Mr Daly told attendees that it was the “biggest health protest” ever seen in Limerick, and that local people had been motivated to attend by the tragic death of Aoife.
16-year-old Aoife Johnston died from bacterial meningitis last December, after a 12 hour A&E wait at UHL. 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. A spokesman for the HSE said in a statement that the review had been shared with Aoife Johnston’s family one year on from her death.
“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.
Aoife’s family had arrived at an overcrowded A&E department on 17th December, with 251 patients attending the hospital’s emergency department on the day in question – one of its busiest ever. A statement released by the HSE this week described an unpublished report into Aoife’s care as “significant in its findings” about the care the teenager received and the operation of the hospital.
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 – while it is a serious complication of an infection, most cases result in a full recovery if identified and treated quickly.
According to the review into Aoife’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.
With the doctors on duty being busy with other patients, the teenager was forced to wait on a chair with her family, and with her condition worsening.
A report in last week’s Sunday Independent claimed that an emergency department consultant who was one of two staff members called to come and support the staff declined to attend the hospital.
The paper reports that according to the review, the consultant said that it was not the function of an A&E department to “sort out overcrowding.”
“A nurse manager called the consultant a second time, but he again declined, according to sources,” the paper reports, adding that the review clarified that the call to the consultant did not specifically relate to Aoife.
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’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 review stated that Aoife and her family were “let down by the systems in place in the emergency department at UHL”.
The new investigation into the teenager’s death will be headed by former chief justice of the Supreme Court, Franke Clarke.
HSE CEO Bernard Gloster who issued a statement on Monday confirming the former judge would be leading the investigation.
“There are many situations in health and social care where analysis of adverse incidents can glean learnings for improvement,” Mr Gloster said in a statement.
“There are also situations where clearly further investigation is required and I am satisfied this is one of those.
“I intend to finalise the Terms of Reference in the coming weeks and have asked Mr Justice Clarke to conduct a timely but thorough investigation.
“I will not be in a position to provide any further details at this time, but again take the opportunity on behalf of the HSE, at the time of her first anniversary to apologise unreservedly to Aoife’s family, recognising no words of mine can ever take away their loss. I do however assure them that the issues raised in the report will be investigated thoroughly.”
Mr Daly, meanwhile, said: “The second investigation with an appointed retired judge is very welcomed, albeit it shows the organisation of the Medical Council of Ireland to be not fit for purpose. when the head of the helm of the HSE CEO Bernard Gloster has brought in a retired judge to oversee an investigation, which would normally be the function of the Medical Council of Ireland.”
“However,” he added, “ I believe personally that Mr Gloster made the right decision with the appointment of a retired judge to investigate.Tthis is what I want myself from the medical Council of Ireland and they have agreed in principle so far that they may do that with regards my own dad’s case.”
Mr Daly said the general feeling across the MidWest region was that the teenager’s death was “100 per cent avoidable,” and that if Aoife had been seen in a timely manner, she would have survived.
He added that the need remains to reopen the three closed A&Es in the region, or to implement some form of action to lower lengthy waiting times before another tragedy occurs.
Another protest highlighting conditions and waiting times at UHL, organised by Mr Daly and the UHL Hospital Protest group, is set to take place on 21st January in Limerick.