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Aoife Johnston died in December 2022.
terms of reference

Investigation into death of Aoife Johnston (16) to probe governance in University Hospital Limerick

The findings of a Systems Analysis Review report were also shared by the HSE.

THE HSE IS to investigate the clinical and corporate governance of University Hospital Limerick in an evidence-based report on the circumstances surrounding the death of Aoife Johnston.

Aoife, 16, died of bacterial meningitis, after a 12-hour wait in the hospital’s emergency department, which was overcrowded at the time, on 19 December 2022.

She had initially presented to the hospital on 17 December, and was eventually admitted to intensive care, but passed away shortly after. 

A report into the circumstances surrounding Aoife’s death has already been carried out, and its findings were recently shared with her family.

An independent investigation, to be carried out by retired Chief Justice Frank Clarke, is now set to look at the circumstances around Aoife’s death and the governance within the Limerick hospital.

The HSE this evening announced that the eight-week investigation will also report on any other factors and/or causes which can be identified for the purposes of improving current and future services.

The Executive also published the full findings of a Systems Analysis Review report alongside the terms of reference for the independent investigation which can be found here.

Clarke may then make recommendations as he sees fit in a written report to be given to the HSE’s CEO Bernard Gloster, according to the document published by the HSE today.

He has also been granted permission to meet with anyone – virtually or in person – who Clake believes can assist with the investigation. All these meetings will be recorded by a third party, Gwen Malone Stenography services.

The purpose of such meetings is to provide an evidence-based analysis and report on the circumstances of Aoife’s death and the overall governance within the Hospital.

Clarke will also be free to seek any information and to raise any issue, which he considers relevant to the investigation.

Clarke will be required to examine documents and conduct interviews. Any particular issue, uncovered during the process of the investigation, which can be viewed as outside of the scope of the probe, will be noted in his report.

The HSE said any refusal or failure to co-operate by any individual will not prevent him from producing a written report.

The evidence gathered during the investigation may later be used to support and can
be relied upon in further processes such as a formal complaint, a HR investigation or for the establishment, exercise or defence of a legal claim.

Clarke can also recommend to extend, vary, amend or clarify to the Terms of Reference to the Commissioner as appropriate and will receive any administrative support that is required, according to the document.

Specialist experts may be engaged with in cases where an expert opinion is required. For the avoidance of doubt, any Specialist Experts may attend any meetings conducted in the course of the investigation – at the discretion of Clarke himself.

SAR Report

A report of the Systems Analysis Review (SAR report), commissioned by the director of University Hospital Limerick (UHL) found that overcrowding, is “endemic” in the hospital’s emergency department.

It found that plans to tackle patient flow, including the appointment of staff to carry out the care and administration of admitted patients in the emergency department (ED), had yet to be fully completed – as none of the appointments of staff had been made.

At the time Aoife had been in hospital, there was “little apparent understanding of the risks and inefficiencies caused to patient care by a crowded environment” in terms of the impact that it can have on the Emergency medicine doctors and nursing staff.

The SAR report said that the the use or misuse of a resuscitation area during her time in hospitals – for monitored interventions – led to crowding and an overemphasis on activity in the space.

The report recommended a dedicated, monitored procedure room be implemented in various Zones in the hospital with adequate staffing.

It was determined that there are “insufficient ED nursing staff” to provide adequate monitoring and care to the patients in UHL at the time, as well as “insufficient Emergency Medicine doctors” to care for the number of patients presenting to the ED that evening.

The SAR report also highlighted an overall, historic high turnover of staff both nursing and EM Non Consultant Hospital Doctors – “which leads to low experience levels and low situational awareness”.

During the time Aoife was in hospital, there was only one Clinical Nurse Facilitator to support nurse integration and education at this time. There was only one EM Consultant who was on-call for the whole weekend, the SAR report found.

National guidelines pertaining to Sepsis management in adults and maternity was not followed on 17 December 2022, when Aoife presented to hospital, which led to a delay in sepsis care of 12 hours.

Additionally, the escalation protocol was not adhered to when Aoife presented to hospital on 17 December, or the night that followed, “despite numbers of patients awaiting an inpatient bed varying between 42 and 55″.

The SAR Report also made findings about how staff supports, such as meeting with staff both directly and indirectly involved in Aoife’s death – deemed “essential” by the report – was not implemented.

The review team said they met with thirty staff members across nursing, administration and medicine and received written reports from two, who were unable to make themselves available for interview.

The report said: “A number of staff, not just those directly involved in [Aoife's] care spoke of the gravity of the impact on hearing of the death of [Aoife].”

Another findings included that some staff were offered informal and formal supports in the immediate aftermath but “there was no evidence of hospital management identifying staff who may have benefited from a support process and then ensuring a structured assistance program being put in place in timely manner”.

The chair of the report team wrote to the Director of UHL, flagging this issue and recommended that staff be offered additional supports, which occurred.

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