Aoife Johnston's death at UHL was 'almost certainly avoidable', report finds
Johnston Aoife
The death of Aoife Johnston at University Hospital Limerick was “almost certainly avoidable”, a report by former Chief Justice Frank Clarke has found.
Ms Johnston, 16, from Co Clare, died on December 19, 2022, after suffering from meningitis-related sepsis and was left for more than 16 hours without antibiotics.
The long-awaited report found that the emergency department was in such confusion that “there was no reality” to care plans that night.
Mr Clarke said there were lost opportunities where someone could have realised how sick she was and taken action. A system to alert staff of patients in crisis proved “inadequate” in light of the high patient numbers that night.
Despite an investigation, issues such as serious communication gaps between staff and managers along with inaccurate X-ray results meant Mr Clarke could not bridge “conflicts of evidence” in some cases.
The report, published on Friday afternoon, was previously criticised by Ms Johnston’s family as “utterly superficial” and they had called for its earlier publication.
Mr Clarke thanked the family for their “quiet dignity” in this process.
“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,” he said.
The medical evidence indicates this tragedy was “almost certainly avoidable”, he said.
While Ms Johnston came to UHL at 5.39pm on December 17 with a letter from an out-of-hours GP service questioning sepsis, she was not prescribed medication until before 6am and only received this between 7.15am and 7.20am the next day.
Among the many distressing details of how sick she became in the report, is a description of her mother assisting the young woman to the bathroom with the use of a wheelchair.
Mr Clarke made 17 recommendations.
The hospital site should be assessed for further expansion and if it is found to be too small to cope with expansion, then another plan must be made.
Communication systems at the hospital should be reviewed.
Detailed recommendations were made around how consultants and nurses interact and what should be expected of them during busy times.
On specific care issues, he advised: “A patient, once seen and prescribed medication by a doctor, should not be waiting over an hour, as happened here, for those medications to be administered.”
In the body of the report, he said overcrowding was so severe that marking her as ‘Category 2’ — the second highest alert level — did not have any effect.
“There was no reality to patients who were categorised in Category 2 being seen by a clinician within anything remotely resembling that timeframe,” he said.
The unit was down five nurses and one doctor below a full roster.
As a result he said the alert “system, if it can be called that, was inadequate to deal with a very difficult situation”.
He said decisions were taken by senior managers about how to reduce the overcrowding, but he concluded: “Managers on the ground were not always as clear as to precisely what had been decided”.