A report into the “avoidable” death of a 16-year-old girl at University Hospital Limerick in 2022 has warned that it could happen again unless bed shortages and overcrowding in its emergency department are resolved.

Aoife Johnston, from Shannon in Co Clare, died of meningitis on December 19th, 2022, at UHL, after she was left for more than 13 hours without antibiotics, a vital treatment to help save her life.

A report into her death by former chief justice Frank Clarke, published on Friday, found she died in circumstances that, on the basis of the medical evidence, “were almost certainly avoidable”.

The retired judge described the emergency department (ED) as “grossly overcrowded”, said the hospital was “significantly understaffed” and had an “inadequate” and “ad hoc” system to escalate concerns about patients’ conditions deteriorating at the time.

The risks he identified to patients “will not be further minimised without addressing the fundamental problem of overcrowding” in the hospital’s ED, he said.

Mr Clarke added that “unless and until” the shortage of beds is addressed it seems likely the ED will “unfortunately but regularly be under pressure” and that despite improvements since 2022, “a risk of reoccurrence will inevitably be present”.

The report, which was commissioned by the HSE after an initial review concluded further investigation was necessary, identified a number of key failings that contributed to Aoife’s death. These included:

Overcrowding and Capacity Issues

The report found that the emergency department at UHL was severely overcrowded, with patients waiting for extended periods to be seen by a clinician. This was a major factor in the delay in Aoife’s diagnosis and treatment.

The report highlighted the fact that several other emergency departments in the midwest region were closed in 2009, leading to a concentration of patients at UHL.

The report also found that the hospital was “significantly understaffed” and that the capacity of UHL was below that recommended in a 2008 report, known as the Horwath report, which had warned that closing other EDs should only occur if the capacity at UHL was increased.

Mr Clarke noted that “some 15 years later, the capacity of Dooradoyle is significantly below that recommended by the Horwath report”.

Communication Failures

The report found that there were significant communication failures within the hospital, which contributed to the delay in Aoife receiving treatment.

Doctors and nurses in the ED were unaware of Ms Johnston’s sepsis risk, the independent report found, as she was brought to an area of the ED where sepsis forms were typically not kept.

The report also found that there was “no reality” to care plans due to the chaotic situation at the ED, leading to missed opportunities to identify and treat Aoife’s sepsis.

Systemic Issues

The report also highlighted a number of systemic issues, including a lack of clear protocols and an ad hoc approach to patient care.

The report pointed out that the hospital's escalation protocol for managing capacity challenges was not implemented effectively, leading to a failure to adequately address the overcrowding issue.

Recommendations

The report made a number of recommendations to prevent similar tragedies from occurring in the future, including:

• Increased capacity at UHL, potentially through a second ED in the midwest region.
• Improved communication systems within the hospital.
• Clearer protocols and guidelines for managing patients with sepsis.
• A review of how doctors and nurses interact and what should be expected of them during busy periods.
• An assessment of the hospital site for potential expansion.

Accountability and Response

The HSE has committed to implementing the recommendations of the report and has already begun taking steps to address the issues raised. The HSE is conscious of the criticism that the report does not make “adverse findings in relation to any individuals”.

However, the HSE maintains that the report provides a pathway to holding individuals accountable for their actions and that this process is already underway.

Public Response

The report has been met with a mix of outrage and concern. Some have criticized the HSE for not taking adequate steps to address the overcrowding issues at UHL, while others have called for greater accountability for those who failed Aoife.

The Irish Nurses and Midwives Organisation (INMO) has called for “meaningful and lasting change” in respect of overcrowding, while the Irish Hospital Consultants Association (IHCA) has described the report as “troubling and telling”.

The report is a stark reminder of the challenges facing the Irish healthcare system and the urgent need for investment in capacity and infrastructure. The tragedy of Aoife Johnston’s death should not be in vain, and the recommendations of the report must be implemented fully and effectively to prevent similar tragedies from occurring in the future.

A Legacy of Sorrow

The death of Aoife Johnston is a tragedy that has left a lasting mark on the Irish healthcare system. The report into her death is a testament to the need for urgent and meaningful change.

This is not just about a single case. This is about systemic failings that need to be addressed to ensure the safety of all patients in our hospitals. We must not allow the tragic death of a young girl to be in vain.

Let Aoife's memory be a reminder that we must demand better from our healthcare system. We must demand better for ourselves, for our loved ones, and for the future generations.