Report says overcrowding and lack of light contributed to Aoife Johnston’s death

A report into the death of Aoife Johnston at University Hospital Limerick said her death was “almost certainly preventable”.

Ms Johnston, 16, from County Clare, died on December 19, 2022, after suffering from meningitis-related sepsis and being left for more than 16 hours without antibiotics.

Former Chief Justice Frank Clarke’s report into Ms Johnston’s death, published on Friday, said the emergency department was “under unusually high pressure” on the night Ms Johnston was admitted to hospital.

The report states that “this investigation follows the tragic death of a sixteen-year-old girl in circumstances which, on the basis of all the medical evidence, could almost certainly have been avoided.”

Ms Johnston was classified as a category 2 patient, meaning she should have been seen by a GP within 10 minutes.

“Given the number of patients classified as category two on the occasion in question and the number of physicians available, there was no possibility that patients classified as category two would be seen by a clinician within anything resembling this time frame.

The report also states that overcrowding at UHL played a significant role in the events of December 17 and 18.

“On 17 December 2022, presenting to triage between 00:00 and 23:59, there were two category 1 patients; 94 category 2 patients, 127 category 3 patients and 14 category 4 patients and 55. 42% of all presentations were therefore category 2. The national average is 22%.

“The data suggest that the ability of doctors and nurses to do their jobs in an ordinary way is materially compromised by overcrowding and can be significantly compromised when overcrowding is severe.”

The report said the failure to identify Ms Johnston as a sepsis patient was also a factor in what went wrong at the time.

“The evidence suggests that none of the nurses or doctors working in the relevant parts of the emergency department during the night were aware that Aoife was a suspected sepsis patient.

“The fact that the sepsis form that should have been prepared for patients with potential sepsis was not completed in Aoife’s case undoubtedly contributed significantly to this lack of knowledge.”

An inquest into Ms Johnston’s death earlier this year returned a verdict of medical accident.

Since Ms Johnston’s death, the report says the emergency department is likely to come under pressure in the future.

“It seems likely that the UHL ED will, unfortunately but regularly, be under pressure and, despite the improvements introduced since 2022, a risk of recurrence will inevitably be present.”

As part of the incident analysis, the report recommends that patients with serious illnesses who are in the emergency room but do not arrive by ambulance be seen more quickly.

“The HSE should consider whether there are ways in which patients who present to the emergency department and potentially require urgent treatment, but who do not arrive by ambulance, can be assessed more quickly at triage, rather than having to wait in a queuing system.”

Mr Clarke said: “Losing a child is every parent’s nightmare. To lose a child in the difficult and traumatic circumstances of Aoife’s death is beyond belief.

“To be there and feel helpless is unimaginable. All we can say is that Aoife’s parents have done everything they can to help her. It’s hard to imagine that it will ever be possible to fully recover from the events of the third weekend of December 2022.

“There are several steps to take to reach even a limited conclusion. We hope that this report will be a step in that direction.”

INMO General Secretary Phil Ní Sheaghdha said: “Our thoughts are with Aoife Johnston’s parents, sisters, extended family and all those who loved her following the tragic circumstances of her death.

“The INMO has long been at the forefront of exposing the systemic issues that exist at University Hospital Limerick. The INMO has been raising the alarm about patient safety issues due to unsafe staffing levels at UHL at local, regional, national and government levels since 2016.

“Our members have long expressed deep and felt frustration at the failure of the whole system to respond effectively, if at all, when clinical issues are raised. Justice Clarke’s report and the systems review by medical and nursing experts commissioned by the HSE must be the catalyst for meaningful and lasting change on overcrowding.

“As we head into another winter filled with unknowns, overcrowding is beginning to increase in hospitals around the world. The most effective way to minimise overcrowding is to adhere to the agreed de-escalation policy before the situation becomes unmanageable. This can only be achieved with sufficient and appropriate inpatient capacity and adequately staffed community services to which patients can be discharged.

“It is clear that safe ratios of nurses to patients must be guaranteed by legislation. The Health Secretary and the HSE Chief Executive must now make this a priority.

“The clinical lessons of Justice Clarke’s report must be learned, including ensuring that there are sufficient numbers of medical and nursing staff to provide safe care to large numbers of patients with complex care needs.

“Overcrowding at University Hospital Limerick has been out of control for far too long. While we recognise the challenges in addressing the entrenched issues within the hospital, there is a need to begin improving internal processes and a complete recalibration at the Dooradoyle campus to change the approach to persistent overcrowding.

“There is a greater need than ever to improve inpatient capacity, while increasing the number of nurses and doctors who can provide care and treatment. The government must now prioritise the creation of additional beds and start recruiting nurses and midwives to ensure patients receive safe care.”

“The Minister for Health and the Chief Executive of the Health Service Executive must outline the immediate steps being taken in this regard. This must start with lifting the recruitment ban and confirming that they will enact the Patient Safety (Licensing) Bill and give HIQA the power to make more than recommendations where safe nursing staffing is not in place.”