Aoife Johnston’s inquest and the HSE

A cara, – Mr John McNamara, presiding coroner at Limerick Coroner’s Court, said of Aoife Johnston’s death that: “There were systemic failures, there were missed opportunities, there were communication breakdowns, clearly.” (“Systemic failures at University Hospital Limerick led to death of Aoife Johnston, says coroner”, April 25th.)

Mr McNamara is right but, mindful that words can never communicate the pain of losing the one you love, I respectfully offer my condolences to Ms Johnson’s family.

There will now be more investigations, reports and the inevitable recommendations; all covered in detail by the media. And then: silence.

At the coalface of the health system nothing will change.

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The Government and the HSE management will continue to use emergency departments as the great “catch-all” for the multiple deficits in the health services over which they preside.

The dedicated doctors and nurses who work in those departments will continue to do so in intolerable conditions.

What should matter of course is that patients will continue to suffer.

So, how can we change human behaviour to prevent the “missed opportunities, systemic behaviour and communication breakdowns” that the coroner outlined in order to reduce the suffering of our citizens and to save their lives?

The two-word answer is “consistent consequences”.

At its most basic level, research, carried out over decades, shows that human behaviour depends on what response there is to that behaviour, whether it be positive or negative and whether it is consistently applied by all.

We implement these principles for our children’s behaviour in their interest, and travelling on a plane would not be so safe were they not to be implemented for all workers in the airline industry.

Most employees in the health service must now show proof of continuous professional development (CPD) and, when something goes wrong, are rightly answerable to their respective regulatory authorities.

If deficits of care are proved, there are consequences for the worker to prevent any such deficit happening again.

Yet, despite being arguably the most vital “cog” in the health system (as they are responsible for service provision), health service managers are not subject to any regulatory authority and do not have to provide evidence of CPD.

Why?

This cannot be easy for managers either but for patients using the health service, such a lack of consistency in managing human behaviour among all the workers providing the service can be catastrophic.

There is no one solution to the problems of the health service. However, if we actually want to improve safety for patients, we have to hold the behaviour of all those providing health services to the same level of account.

This means we need the same level of regulation for all.

Our loved ones deserve nothing less. – Yours, etc,

DR KIERAN MOORE,

Consultant Paediatric Psychiatrist,

Ros Mhic Triúin,

Co Chill Cheannaigh.