An investigation into the death of 16-year-old Aoife Johnston, who died at UHL in December 2022 has found that doctors and nurses at the Emergency Department were unaware of her sepsis risk, and because of overcrowding she was sent to the wrong section of the ED where sepsis forms were not kept or filled out.
The report, carried out by former Chief Justice Frank Clarke, also speaks of what he describes as the serious conflicts of evidence among staff about patient flow protocols to alleviate overcrowding and how they did not operate on the night of her admission to the ED, which meant that the overcrowding was more severe than it should have been.
The report says the investigation into her tragic death arose in circumstances which, on the basis of all the medical evidence given to him, were almost certainly avoidable.
First of all, there was an hour delay in Aoife being triaged once she arrived in the hospital. The possibility of sepsis was queried by her GP who sent her there and by the nurse [not identified] who saw her in triage. The national protocol suggests that treatment should take place within one hour.
However, because of the overcrowding, Aoife was not brought to the Resus area where sepsis forms are normally kept, and where she should have been brought to - given the possibility of sepsis, and instead was brought to Zone A, where sepsis forms are not kept.
Because she bypassed the Resus area, no sepsis form was filled out.
This, Mr Clarke says, undoubtedly contributed to the fact that it appears that none of the doctors or nurses in Zone A were aware that Aoife had been initially identified as being at risk of sepsis.
There are also conflicts about requests to doctors to see her as her condition worsened, and to move her up the queue of awaiting patients. Mr Clarke says it is clear from the evidence that her parents and many other patients waiting to be seen in the ED became increasingly concerned about her condition and expressed that as best they could.
Read more:
Aoife Johnston: A story of systematic failures and missed opportunities
HSE failures 'catastrophic' for Aoife Johnston - Gloster
'Unclear' who was in charge at UHL site - HSE review
Clarke report makes 17 recommendations for UHL Emergency Dept
He also said there was a serious conflict of evidence about why the patient escalation protocol to relieve overcrowding did not happen.
Mr Clarke said a lack of clarity about this contributed to a delay in Aoife being treated. Nurse managers on the ground did not have a clear understanding in respect of the issue, and were not always clear about the decisions taken at senior management level and what precisely had been decided.
A significant and material conflict has emerged in respect of whether or not an instruction was given that trolleys bearing admitted patients were to be placed on wards that night and morning of 17 and 18 December in an effort to ease pressure on the ED.
Mr Clarke also references the capacity issue at UHL, and how the increased capacity in beds did not happen at UHL when the other three EDs in the region were closed in 2009, and that this is a very significant contributory factor to the general overcrowding.
In assessing what went wrong, Mr Clarke said ultimately the evidence suggests that none of the nurses or doctors who were working in the relevant part of the ED over the course of the night were aware that Aoife was a suspected sepsis patient.
The fact that the sepsis form which ought to have been prepared in respect of potential sepsis patients was not filled out in Aoife's case was undoubtedly a significant contribution factor to that lack of knowledge.
In his overall conclusions, Mr Clarke said some of the measures which have been adopted since Aoife Johnston's death "may well reduce the risk of similar events occurring in future".
However, he said: "All of the evidence seems to me to confirm that these risks will not be further minimised without addressing the fundamental problem of overcrowding in ED."
Mr Clarke said the position in ED at UHL "is inextricably linked with the overall capacity of the hospital".
He said on many occasions patients are "boarded" in the ED "simply because there are no beds to which they can be moved" in the hospital.
As a result of that challenge, Mr Clarke warned that a repeat of the tragedy in December 2022 "will inevitably be present".
He said: "Unless and until that problem is addressed, then it seems likely that UHL ED will, unfortunately but regularly, be under pressure and, despite the improvements introduced since 2022, a risk of reoccurrence will inevitably be present."
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Additional reporting: Fergal O'Brien
