The investigation into the death of 16-year-old Aoife Johnston in University Hospital Limerick more than a year ago is to be completed within eight weeks.
Former chief justice Mr Justice Frank Clarke has been tasked with providing an evidence-based report into the teenager’s death and into “the clinical and corporate governance” of UHL, according to the terms of reference of his investigation.
“The independent investigation will also report on any other factors and/or causes which can be identified for the purposes of improving current and future service delivery,” the terms of reference published by the HSE on Tuesday state.
Aoife Johnston, from Shannon, Co Clare, died in the hospital in December 2022 after waiting for 12 hours to be treated in the emergency department. She was diagnosed with bacterial meningitis and later developed sepsis.
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Her death was the subject of an internal HSE report, which was given to its chief executive Bernard Gloster last month.
This report found there was a 12-hour delay in caring for Aoife Johnson’s developing sepsis. On the weekend she was in the hospital, UHL’s full escalation protocol was triggered despite the number of patients awaiting an inpatient bed varying between 42 and 55.
Overcrowding was endemic in the hospital’s emergency department and that was “little apparent understanding” of the risks this posed, the internal report by two non-UHL doctors also found.
There were insufficient ED nursing and medical staff to adequately monitor patients and a high turnover of staff, leading to “low experience levels and low situational awareness”.
There was only one ED consultant on call for the whole weekend the teenager was in the hospital: “As they cannot be present all the time, this leads to them providing specific supports only. This has led to an expectation gap.”
Following the Aoife Johnston’s death, there was no evidence of hospital management identifying staff for support and “structured assistance”, the investigators also noted. Such was the “evident trauma of the staff”, recommended additional supports be provided.
Commenting on Tuesday, Mr Gloster said: “The judge has been asked to make any recommendations as he sees fit and to report directly to me.”
On the day the 16-year-old died, UHL said it was dealing with “unprecedented” demand on its emergency department, which had led the hospital to cancel “all but the most urgent elective surgeries”.
In a statement at the time, the hospital warned anyone with a “less urgent condition” attending the emergency department that they would likely face “an exceptionally long wait for care”.
Doctors and staff had repeatedly raised concerns about overcrowding in the hospital’s emergency department.
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