Stephen Donnelly welcomes report into death of teenager who died from sepsis

MINISTER for Health Stephen Donnelly has said that work "is now underway in the HSE to implement" recommendations outlined in the report into the death of teenager Aoife Johnston at the emergency department at University Hospital Limerick.

The report, published earlier this Friday, outlines how staff at 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, which led to her death on December 19 that year.

In his report, which runs for over 200 pages, former Chief Justice Mr Frank Clarke SC 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.

Welcoming the publication of the report this Friday, September 20, Minister Donnelly said that "work is now underway in the HSE to implement Mr Clarke’s recommendations and to build on the improvements already made at UHL since 2022, as acknowledged in Mr Clarke’s report."

He said that his thoughts were with Aoife Johnston's family, "as they deal with the devastating loss of their beloved daughter and sister".

Read Also: Clare teen who died of sepsis sent to wrong section of hospital ED, report finds

HSE chief Bernard Gloster has said the “very detailed” report will provide “a pathway to accountability”.

He said that accountability had to be addressed by him as the employer, and that the accountability process had begun in relation to “several people”.

“Were it not for Mr Justice Clarke’s report, which I now have, I would not have been able or in a position to formulate the concerns I now have based on the evidence and to commence investigations under our disciplinary procedures," Mr Gloster said.

However, solicitor for the Johnston family Damien Tansey said that it was “utterly bewildering” to claim that an independent inquiry was needed to progress disciplinary proceedings.

“That is utter rubbish,” he said.

“The family are very concerned about the fact that this is a public interest story, the public have a great interest in this, most especially the 1.2 million people in the Midwest region that are serviced by University Hospital Limerick.”

“Aoife Johnston and the family are in the glare of publicity since her death and that continues. And yet the people who caused it are entitled, according to the HSE, to anonymity,” Mr Tansey continued.

He said that when wrongdoing is exposed, “part of the sanction” is public disclosure.

He said the release of the report on Friday was “unbelievably difficult” for the family.

“It really is unimaginable what they’re going through.”

The Irish Nurses and Midwives Organisation said that the report into the death of the teenager "must be the catalyst for meaningful and lasting change in respect of overcrowding" at the ED in UHL.

In a statement, INMO General Secretary Phil Ní Sheaghdha said that their members had co-operated fully with Mr Clarke's investigation, and that thet had "long been to the fore of calling out the systemic problems that exist in University Hospital Limerick."

"The INMO has been sounding the alarm on issues of patient safety due to unsafe staffing levels in UHL at local, regional, national and governmental levels as far back as 2016," Ms Ní Sheaghdha continued.

“Our members have long expressed deep and have felt frustrations arising from the failure of the entire system to respond effectively, or at all, when clinical concerns were raised".

The Irish Hospital Consultants Association also released a statement following the publication of the report, calling for "transparency, collaboration, and swift action" by the HSE to restore trust in UHL.