The HSE has today published the full report conducted by former Chief Justice Frank Clarke into the tragic death of Shannon Teenager Aoife Johnston at University Hospital Limerick.
Ms Johnston passed away from bacterial meningitis on December 19th 2022 after waiting 12 hours on chairs in UHL’s Emergency Department after suspected sepsis went untreated.
Bernard Gloster commissioned the Clarke report, having considered the conclusions of a System Analysis Review and having determined that further investigation was necessary.
Prefacing the report, Justice Clarke thanked Aoife’s parents for the quiet dignity of their evidence To lose a child in the fraught and traumatic circumstances of Aoife’s death is beyond understanding and that Aoife’s parents did everything possible to assist her.
According to Justice Clarke, on the basis of all the medical evidence, the circumstances in which Aoife died were almost certainly avoidable.
Aoife Johnston presented at the Emergency Department in University Hospital Limerick at 17.39 on the late afternoon of Saturday, December 17th 2022 with a letter of referral from an out of hours GP service querying sepsis but was not administered the appropriate sepsis bundle of medication until between 7:15 and 7:20am the following morning.
There was thus a thirteen and a half hour gap between presentation and treatment.
Up to 191 patients were in attendance at the ED on the night Aoife was admitted, and this capacity was catered for by just 19 nurses and 1 clinical nurse manager in charge.
Throughout the night, 4 staff nurses who were not trained in emergency medicine provided breaks.
According to Justice Clarke, There is no evidence to suggest the reason for the delay in Aoife being triaged was due to anything other than the number of patients presenting—it took over an hour before Aoife reached the top of the queue of those arriving in the Emergency Department.
Unlike most patients who are considered to be at risk of sepsis, Aoife was not brought to the Resus area after triage as that area was already grossly overcrowded, but rather was brought to Zone A in the Emergency Department.
Given the numbers of patients presenting, it was inevitable that there would have been significant overcrowding in any event.
However, according to the report, the escalation protocol designed to alleviate overcrowding in the Emergency Department was not operated until well into the morning of Sunday 18th.
Justice Clarke therefore found, the overcrowding in the Emergency Department overnight was undoubtedly more severe than it should have been.
Due to the scope of the terms of reference of the Clarke Report, additional healthcare resources are not among the 17 recommendations, however the 2009 Howrath report which paved the way for the closure of A&Es at Ennis, Nenagh and St. John’s in referenced.
According to Justice Clarke, It is clear that, for the implementation of its reconfiguration recommendations, the hospital site at Dooradoyle required a very significant number of new inpatient beds, which did not materialise
The Clarke Report has recommended the HSE to determine whether there are circumstances in which it could be recommended that a GP, on identifying a risk of sepsis in a patient, takes the initial treatment steps required at that time while also referring the patient to an ED and for the HSE to give consideration to identifying whether there are ways in which patients who attend at the Emergency Department and who are potentially in need of urgent treatment, can be assessed in triage more quickly.
Aoife Johnston was declared dead at 15.31 on the 19th December 2022 with her family in attendance.
Statement from HSE CEO Bernard Gloster
“I want to thank Mr Justice Clarke and his team for the excellent report and the thoroughness of the work. This report has enabled us already to bring clarity to the concerns that arise from Aoife’s case based on a consideration of the evidence. It has given us a pathway to both learning and accountability. That accountability is and will be pursued fairly and appropriately in a confidential process. The learnings from the report and the recommendations are all being actively considered in the many aspects of improvement that are underway and indeed have relevance to assisting the overall patient safety agenda in all our settings.”
Mr Clarke’s report does not make adverse findings in relation to any individuals. The HSE is conscious of the criticism of this and would wish to emphasise the following by way of response.
Mr. Clarke made it clear in Chapter 10 that the Terms of Reference did not allow for the making of adverse findings against individuals or resolving conflicts of fact. If the Terms of Reference had provided for such findings it would have been a much more prolonged process which would have had to ensure that any individuals, who might be the subject of any such adverse finding, were given the full opportunity (with legal representation etc.) to present their own side of events and challenge any evidence through cross-examination. Mr. Clarke made it clear that “it is not possible to have it both ways and have a timely resolution while at the same time complying with the obligations of procedural fairness.”
Most importantly, if the report, commissioned by the HSE CEO, had included such adverse findings against any HSE employee it would have represented an unlawful contravention of their legal and contractual rights, and the Report would have been likely to be struck down in the courts.
He went on to say “… it would not have been possible to conduct the sort of process which might give rise to the possibility of adverse individual findings in anything remotely like the timescale specified in the Terms of Reference.”
The HSE is also today publishing the report of the UHL Support Team, which was established on April 30th last to Support the Region in addressing some of the pressures that are experienced there. The team advised on several actions designed to ease overcrowding and pressures in the Emergency Department at University Hospital Limerick. The HSE is grateful to Ms Grace Rothwell, National Director, Ms. Orla Kavanagh Director of Nursing and Retired Emergency Medicine Consultant Dr Fergal Hickey.
Commenting further on today’s publications Bernard Gloster said “Mr. Justice Clarke has given a timely and sound report, probably the most such that I can recall in my career. We failed Aoife and our failure has resulted in the most catastrophic consequences for her and her family. It is only right and proper that there is appropriate accountability based on evidence, facts and that it is lawful in how it is pursued. We now have that. It is also important to have learning to improve patient safety based on that same evidence. When all is said and done today must be about Aoife and her family, recognising that all the reports and processes will not undo the harm caused to them. For that we are and must remain truly sorry. May she rest in peace.”
