The death of a Shannon teenager in the overcrowded Emergency Department at University Hospital Limerick (UHL) was “almost certainly avoidable”, a new report has revealed.
Aoife Johnston, Cronan Lawn, Shannon, died of meningitis in December 2022 after a thirteen and a half hour gap between presentation at the Emergency Department having been seen by a GP who queried the possibility of sepsis and where the risk of sepsis was also identified by Nurse A who dealt with her, according to a new report.
The Frank Clarke report was commissioned by HSE CEO Bernard Gloster after he received the report of a Systems Analysis Review (a SAR report), prepared under the HSE’s National Incident Management System (NIMS). Mr Gloster commissioned the Clarke report having considered the conclusions of the SAR and having determined that further investigation was necessary.
At the start of his 247-page report, Justice Frank Clarke recognised this Investigation arose out of the tragic death of a sixteen year- old girl in circumstances which, on the basis of all of the medical evidence, were almost certainly avoidable.
He thanked Aoife’s parents for the quiet dignity of their evidence.
“That human tragedy and the inevitable consequences for her family and friends mandates a thorough investigation.
“To lose a child is every parents’ nightmare. To lose a child in the fraught and traumatic circumstances of Aoife’s death is beyond understanding. To be present and feel powerless is unimaginable.
“All that can be said is that Aoife’s parents did everything possible to assist her. It is hard to imagine that it will ever be fully possible to get over the events of the third weekend of December, 2022.
Mr Clarke outlined the fundamental issue concerned the fact that Aoife Johnston presented at the Emergency Department in University Hospital Limerick at 17.39 on the late afternoon of Saturday December 17th 2022 with a letter of referral from an out of hours GP service querying sepsis but was not administered the appropriate sepsis bundle of medication until between 7:15 and 7:20am the following morning.
All of that needs to be seen in light of the National Protocol on sepsis which suggests that treatment should take place within one hour.
Having reviewed the evidence, he stated there was at least some evidence to support a view there appeared to be a lack of clarity amongst managers on the ground as to some of the procedures and processes which were in place and which at least had some bearing on the events of the 17th and 18th December.
Mr Clarke identified several systems and pathways of care in the hospital which appear to have been either in place and not implemented or not in place other than in an ad hoc way. These included critically the sepsis pathway and the escalation protocol for managing the capacity challenge.
The Report identifies a number of factors that contributed to delayed treatment and Aoife’s death, including unclear protocols, ad hoc systems, poor internal communication and a failure to deploy the escalation protocol.
It cited the capacity issues impacting the hospital post reconfiguration and having regard to the population growth and the demand on the particular weekend.
The report was commissioned by the CEO of the HSE Bernard Gloster after he received the report of a Systems Analysis Review (a SAR report), prepared under the HSE’s National Incident Management System (NIMS). Bernard Gloster commissioned the Clarke report having considered the conclusions of the SAR and having determined that further investigation was necessary.
Bernard Gloster said this report has enabled the HSE already to bring clarity to the concerns that arise from Aoife’s case based on a consideration of the evidence.
“It has given us a pathway to both learning and accountability. That accountability is and will be pursued fairly and appropriately in a confidential process. The learnings from the report and the recommendations are all being actively considered in the many aspects of improvement that are underway and indeed have relevance to assisting the overall patient safety agenda in all our settings.”
Mr Clarke’s report does not make adverse findings in relation to any individuals. The HSE is conscious of the criticism of this and would wish to emphasise the following by way of response.
Mr Clarke made it clear in Chapter 10 that the Terms of Reference did not allow for the making of adverse findings against individuals or resolving conflicts of fact.
If the Terms of Reference had provided for such findings it would have been a much more prolonged process which would have had to ensure that any individuals, who might be the subject of any such adverse finding, were given the full opportunity (with legal representation etc.) to present their own side of events and challenge any evidence through cross-examination.
Mr Clarke made it clear that “it is not possible to have it both ways and have a timely resolution while at the same time complying with the obligations of procedural fairness.”
Most importantly, if the report, commissioned by the HSE CEO, had included such adverse findings against any HSE employee it would have represented an unlawful contravention of their legal and contractual rights, and the Report would have been likely to be struck down in the courts.
Mr Gloster stated it would not have been possible to conduct the sort of process which might give rise to the possibility of adverse individual findings in anything remotely like the timescale specified in the Terms of Reference.
“We failed Aoife and our failure has resulted in the most catastrophic consequences for her and her family. It is only right and proper that there is appropriate accountability based on evidence, facts and that it is lawful in how it is pursued. We now have that.
“It is also important to have learning to improve patient safety based on that same evidence. When all is said and done today must be about Aoife and her family, recognising that all the reports and processes will not undo the harm caused to them. For that we are and must remain truly sorry. May she rest in peace.”
Health Minister Stephen Donnelly said his thoughts are with Aoife’s family.
“I know that each day is difficult for them as they deal with the devastating loss of their beloved daughter and sister. Their grief has been compounded by the circumstances, and failings, that led to her untimely death.
“The Report highlights the particularly severe pressures that night in the Emergency Department. HIQA has been asked to lead a review into urgent and emergency care capacity in the Midwest region, including to determine whether a second Emergency Department is required.
“Work is now underway in the HSE to implement Mr Clarke’s recommendations and to build on the improvements already made at UHL since 2022, as acknowledged in Mr Clarke’s report.
“Implementation of Mr Clarke’s recommendations, as well as the actions and changes recommended by the HSE expert clinical review also published today, are important for the patients of the Midwest, as well as the staff in UHL, to rebuild confidence in the safety and quality of the care and services provided there.”
Dan Danaher
East Clare correspondent, Dan Danaher is a journalism graduate of Rathmines and UL. He has won numerous awards for special investigations on health, justice, environment, and reports on news, agriculture, disability, mental health and community.