The family of 16-year-old Aoife Johnston who died in University Hospital Limerick (UHL) in 2022 has declined to meet the chief executive of the health service again until after the independent report into her death has been published in full.

Aoife Johnston, from Shannon in Co Clare, died of meningitis on December 19th, 2022, at UHL, after she was left for more than 15 hours without antibiotics, a “vital” treatment to help save her life.

An inquest into her death earlier this year recorded a verdict of medical misadventure, with Dr Jim Gray, the emergency medicine consultant on call that weekend, describing the emergency department as “like a death trap” due to overcrowding.

An investigation into her death, conducted by former chief justice Frank Clarke, was completed two months ago.

The family have said they were incredibly disappointed by the report, which is understood to not have made any adverse findings against any individuals or to have resolved a number of conflicts.

Bernard Gloster, chief executive of the Health Service Executive, extended an invitation to the family earlier this month to meet him to discuss publication of the report.

However, The family have decided they will not meet the HSE until the full, unredacted report has been published.

There will also be no further engagement between the family and Philip Lee, Mr Gloster’s solicitor, until this has been done.

It is understood the family have referred to the recent Grenfell Tower Inquiry and the Mary O’Toole scoping inquiry into historical sexual abuse in schools run by religious orders as recent examples of reports being published regardless of other proceedings.

Frustration and Shortcomings

Damian Tansey, the family’s solicitor, said they “want the unredacted report to be published. End of story” as they want to highlight “its shortcomings”.

Asked what would happen if the report is not published, Mr Tansey said he could not direct the Johnston family on what they should do and “what they do with the report is entirely up to them”.

Public Apology

The University of Limerick Hospital Group and the HSE previously apologised publicly to the Johnston family. Mr Gloster said the health service “failed” Ms Johnston and that failure “led to her death”.

“There is only one thing that we can say to them, and that is that we apologise, we are sorry,” he said on radio after her inquest. “We failed Aoife, our failure led to her death. We failed them as a family.”

Asked about the publication of the report, a spokesman for the HSE said: “The chief executive has said he will publish the report later this month in an appropriate format, which must take into account the HSE’s obligations to all parties involved and must respect the personal and sensitive data contained in the report.”

Timeline of Events

Here is a timeline of the events leading up to Aoife Johnston's death:

• December 17, 2022 5.40pm: Aoife (16), a Leaving Cert student from Shannon, Co Clare, presents at UHL’s A&E with suspected sepsis. 7.15pm: Aoife is triaged as query sepsis and left to wait.
• December 18, 2022 5.45am: Aoife is assessed and prescribed antibiotics. 7.15am: Aoife receives antibiotics and is left on a trolley. 8am: Aoife’s father roars for help, a nurse finds Aoife “distressed, tearful and agitated” and her limbs moving involuntarily. She is intubated and transfers to ICU.
• December 19, 2022 3.31pm: Aoife dies from purulent meningitis.
• December 2023: Aoife’s family receive a damning internal review of her care highlighting missed opportunities and breach of national sepsis guidelines.
• December 18, 2023: HSE chief Bernard Gloster appoints former chief justice Frank Clarke to investigate, citing need for accountability.
• April 26, 2024: Inquest rules Aoife’s death a medical misadventure.
• July 2024: Frank Clarke submits his report to Mr Gloster who begins a disciplinary process against several senior staff.
• August 2024: Johnston family informs HSE of their “profound disappointment” with a report that fails to draw adverse conclusions or resolve conflicts around Aoife’s death.

The family's decision to withhold further engagement with the HSE highlights the deep distrust and anger they feel towards the health service, particularly in light of their belief that the report has failed to adequately address the circumstances surrounding Aoife's death. Their refusal to meet with the HSE chief executive until the full report is published is a powerful statement about their demand for transparency and accountability. This case has once again brought into sharp focus the serious challenges facing the Irish healthcare system, particularly the issue of overcrowding and the need for urgent action to address these issues. The ongoing controversy surrounding the report into Aoife Johnston's death is likely to continue, with the family's determination to ensure that the full truth surrounding her tragic death is made public. The public will be watching closely to see how the HSE responds to the family's demands for transparency and accountability.