*University Hospital Limerick.
AOIFE JOHNSTON’s death must be “a watershed moment” for University Hospital Limerick and health services in the Mid-West region.
Health activists and politicians have labelled the Clarke Report into the death of the Shannon teenager as “harrowing”.
A spokesperson for Friends of Ennis Hospital told The Clare Echo, “It shows that systematic systems failures across several layers of medical and management staff in UHL caused the ‘almost certainly avoidable’ death of a 16 year old. Our hearts break all over again for her family, friends and loved ones as Justice Clarke lays out the failures in her care from the moment of admission. To say that ED in UHL on the night of December 17th 2022 was ‘operating’ more by good luck than good guidance is not an exaggeration.
“Aoife Johnston was failed by the HSE. She was failed by systems that are not fit for purpose. She was failed by management who told the Dail Joint Committee on Health a mere three months previously (21/09/22) that ‘UHL continues to provide safe, quality services for its patients’. And she was failed by staff who are now facing disciplinary proceedings as a result of her death. Aoife Johnston was also failed by us, both the public and the health campaigners who did not shout loud enough, or long enough or often enough about the failures we saw and continue to see in UHL. Our children should not be dying of treatable conditions in our acute hospitals in a first world country in the 21st century. Aoife Johnstons death must be a watershed moment for University Hospital Limerick & the wider Midwest Region,” the spokesperson added.
Shannon based Cllr Donna McGettigan (SF) described the report as heart-breaking and that it shows a compelling case for a second model three hospital with an emergency department in the Mid-West. “The conclusion of the Clarke Report that Aoife Johnston’s death was ‘almost certainly avoidable’ is heart breaking. My thoughts are with her family, friends, and loved ones, whose pain is unimaginable”.
She added, “The report is devastating in its critique of the closure of emergency departments in Ennis and Nenagh, a chronic lack of capacity at UHL, and a litany of failures in management and adherence to sepsis protocols. Aoife faced delay at every stage, from admission, triage, and assessment, to treatment, which left her waiting for more than 13 hours for care which should have been administered immediately, since her GP had already identified sepsis risk”.
Cllr McGettigan said, “It has been known for the last fifteen years that UHL was in need of major expansion to serve as the sole major hospital for the Mid-West. A litany of failures in management meant that, despite the emergency department being massively overcrowded, escalation and crisis management protocols were not implemented. As a result, Aoife was placed in the wrong part of the hospital because the resuscitation area, where she should have been as a suspected sepsis patient, ‘was already grossly overcrowded’. It seems that management did not have a back-up plan for this eventuality, and that a reliance on a pen and paper system in the middle of a crisis meant that staff could not be aware of or properly respond to Aoife’s condition. The lack of a back-up plan for the resuscitation area in particular, and the single-point-of-failure that is UHL ED as a whole, meant that there were no services available to support UHL during a crisis”.
Clare TD, Violet-Anne Wynne (IND) pointed out that there were countless failures in UHL on the night of Aoife’s death. “Those failures as far as I can see were three pronged: The failure of the chain of command and management, the failure of the alert system used, and the catastrophic overcrowding which was and still is a direct result of the failure to properly implement the 2008 Horwath Report. In closing the Ennis ED before ensuring that the Dooradoyle facility had the capacity to handle the obvious increased case load, the government of the day doomed UHL to struggle into a centre of chaos, a far cry from excellence as promised. Every politician that voted in favour of that decision traded political capital for uncountable suffering”.
