A REPORT into the death of a teenager at University Hospital Limerick (UHL) has said her passing was 'almost certainly avoidable'.
Aoife Johnston, 16, waited more than 13 hours for sepsis medication, despite her parents and fellow patients expressing concern over her worsening condition.
In his report, former Chief Justice Frank Clarke highlighted failures in hospital procedures, adding: "To lose a child in the fraught and traumatic circumstances of Aoife's death is beyond understanding."
Delays
Ms Johnston. From Co. Clare, was taken to UHL by her parents at around 5.20pm on Saturday, December 17, 2022 with a letter from a GP querying sepsis.
Following more than an hour wait, Ms Johnston was seen by a triage nurse, who also identified symptoms of sepsis.
However, she was not brought to the Resus area — where patients at risk of sepsis are normally taken — due to overcrowding in that department and was instead brought to the Emergency Department.
Forms that normally accompany a patient suspected of sepsis were only kept in the Resus area, so no such paperwork was filled in for the teenager, meaning staff in the Emergency Department were unaware of the risk.
A doctor prescribed Ms Johnston with prescribed Paracetamol, Ondansetron and Zofran, which was administered at 8.25pm, but she was not moved to a trolley until around midnight.
In the following hours, a second nurse said they went to Resus at around 1.40am and again at 4am and spoke to two different doctors about the girl's situation.
While the report highlights conflicts of evidence, the timeline of events in the report claims both doctors said they were unable to come and review the teenager due to acuity in the Resus area.
The nurse raised their concerns with a third doctor, who saw Ms Johnston at around 6am and prescribed the correct sepsis medication and requested an x-ray.
However, it was more than an hour before both the medication was administered and the x-ray taken.
The doctor who prescribed the medication said porters got annoyed when Ms Johnston's mother said her daughter — who had suffered during the night from vomiting, low blood pressure, high temperature and pains in her legs — did not initially feel up to an x-ray.
Ms Johnston was eventually moved to Resus later on the morning of December 18 but was sadly declared dead the following afternoon.
'Beyond understanding'
Opening his report, Mr Clarke said: "It is important to start by recognising that this investigation arises out of the tragic death of a 16-year-old girl in circumstances which, on the basis of all of the medical evidence, were almost certainly avoidable."
He added: "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."
In his report, Mr Clarke determined that systems and pathways of care in the hospital were not implemented or were done so in an ad hoc way, including the sepsis pathway and the escalation protocol.
He also raised concerns about capacity issues and gaps in communication between the senior management of the hospital and frontline managers.
He said: "To reduce the possibility of a similar situation arising in the future it is recommended that the communications systems in UHL and the wider hospital group are reviewed with a view to ensuring that when important decisions are made at Senior Management level they are effectively and clearly communicated to managers on the ground."
Among Mr Clarke's other recommendations were reviews into communication systems, providing more resources for triage, administering medication and limiting admissions to Resus to patients 'whose clinical requirements necessitate their being in such an area'.
'Failure'
Commenting on the report, Bernard Gloster, CEO of the Health Service Executive (HSE), said the HSE 'failed' Ms Johnston.
"Mr Justice Clarke has given a timely and sound report, probably the most such that I can recall in my career," he said.
"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."
Meanwhile, Minister for Health Stephen Donnelly said: "My thoughts today are with Aoife's family.
"I know that each day is difficult for them as they deal with the devastating loss of their beloved daughter and sister.
"Their grief has been compounded by the circumstances, and failings, that led to her untimely death."
