BREAKING: Aoife Johnston sent to wrong section of UHL emergency department, report finds

EMERGENCY department staff at University Hospital Limerick (UHL) were not made aware of Aoife Johnston's sepsis risk on the day she was admitted in December 2022, and she was sent to a section of the ED where sepsis forms were not kept or filled out.

That's according to the long-awaited report, published this Friday afternoon by the HSE, from former Chief Justice Mr Frank Clarke SC on the independent investigation that he led into matters connected with the tragic death of Aoife Johnston at UHL on December 19, 2022.

In his report, which runs for over 200 pages, Mr Clarke highlighted serious conflicts of evidence among staff about patient flow protocols to alleviate overcrowding and how these were not in place on the night of Aoife's admission to the ED, which meant that the overcrowding was much more severe than it should have been.

He details how it took Aoife an hour to be seen by a triage nurse after her parents brought her to the ED at UHL, despite having been identified by her GP as having a risk of sepsis due to a bacterial meningitis infection.

Read Also: Family of late Aoife Johnston 'profoundly disappointed' with report into her death

Aoife was then brought to Zone A of the ED, instead of to the Resus area where patients typically considered to be risk of sepsis are brought, as it was "grossly overcrowded".

However the report notes that forms that should normally accompany a patient identified as being at risk of sepsis "were, at the time, only kept in the Resus area", and none was filled out for Aoife when she bypassed Resus.

"This undoubtedly contributed to the fact that it appears that none of the nurses or doctors who were involved in dealing with patients in Zone A were aware that Aoife had been identified both by a GP and by [the triage nurse] as being at risk of sepsis," Mr Clarke stated in his report.

As a result of this it was over 12 hours after Aoife presented to the ED at UHL with a letter from her GP identifying her as being at risk of sepsis when the "appropriate bundle of medication" for sepsis was administered.

The clinical advice for sepsis states that such medications be administered within one hour.

"Clonflicts of evidence" were also identified by Mr Clarke over Aoife being seen by a doctor and an x-ray being obtained for her.

He also outlined underlying factors which led to the delay in Aoife's treatment, such a serious "lack of clarity" over how nursing managers were expected to deal with overcrowding at UHL, and the major understaffing levels at the ED that night in December 2022.

On the night of December 17/18, the report states that "the number of nurses was five less than the full roster by reason of absences with the number of doctors being also one below full roster".

Nursing managers on the ground did not have a clear understanding of the patient escalation protocol at UHL to relieve overcrowding, and that  decisions taken at senior management level weren't clearly communicated to frontline management, the report said.

Mr Clarke also drew attention to the overall capacity of UHL itself to absorb all admitted patients from the ED, calling it a "significant contributory factor to the general overcrowding in UHL’s Emergency Department" that stemmed directly from the decision in 2009 to close all other emergenncy departments in the Mid-West region and concentrate all acute emergency patients at UHL.

In his report, Mr Clarke hailed Aoife’s parents for the "quiet dignity of their evidence", and said that to lose a child in the "fraught and traumatic circumstances of Aoife’s death is beyond understanding" and "every parent's nightmare".

"There are many steps to even some limited measure of closure. It is hoped that this report may be one step along that journey," Mr Clarke stated.

Speaking after the release of the report, CEO of the HSE Bernard Gloster said that the report had "enabled us already to bring clarity to the concerns that arise from Aoife’s case based on a consideration of the evidence".

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," Mr Gloster continued.

He also recognised that "all the reports and processes will not undo the harm caused" to Aoife's parents and her family, fro which the HSE "are and must remain truly sorry".