A “grossly overcrowded” emergency department and “lack of clarity” on sepsis protocols have been identified in a report examining the death of Aoife Johnston at University Hospital Limerick.
The 16-year-old died at the hospital in 2022 after waiting for 12 hours to be assessed for suspected sepsis.
Aoife presented to the hospital’s emergency department (ED) at 5.39pm on Saturday December 17 2022 following a referral from an out-of-hours GP service which had queried the possibility of sepsis.
She was not administered the appropriate sepsis bundle of medication until 13 hours later, between 7.15am and 7.20am. National protocols on sepsis suggest that treatment should take place within one hour.
She was pronounced dead on December 19.
The Health and Safety Executive (HSE) published a report by former chief justice Frank Clarke on the independent investigation into what he described as the “almost certainly avoidable” circumstances of her death.
Mr Clarke’s report identifies a number of issues including several care pathways which appear not to have been in place or properly implemented, including the sepsis pathway and escalation protocol for overcrowding.
It also examines concerns about gaps in communication between the senior management of the hospital and the frontline managers running the services on the ground.
Additionally, capacity issues in the hospital are heavily emphasised.
The report finds that it took more than an hour for Aoife to reach the top of the queue for those arriving in the ED other than by ambulance.
Unlike most patients who are considered to be at risk of sepsis, Aoife was not brought to the resuscitation area after triage, which at the time was the only place that the relevant sepsis forms were kept. The triaging nurse wished to send Aoife to the resuscitation area because of a concern over sepsis.
However, she was not been brought to the resuscitation area as it was “grossly overcrowded”. Aoife was taken to a different area identified as Zone A.
Mr Clarke said the fact that no form was filled out “undoubtedly contributed” to no doctor or nurse being aware that Aoife had been identified as being at risk of sepsis.
While noting there is conflicting evidence on Aoife’s worsening condition, Mr Clarke adds that both of her parents, many other patients waiting to be seen in the emergency department and another nurse became “increasingly concerned” and expressed those feelings “as best they could”.
As a result of a request from the second nurse, Aoife was seen by a doctor just before 6am on the Sunday morning.
The appropriate sepsis bundle of medication was prescribed and it was also determined that she should have an X-ray.
However, more than one hour elapsed before she was administered the medication – which Mr Clarke said “clearly makes no sense”.
On the underlying factors that led to the delay in treatment, Mr Clarke said it is an “undoubted fact” that the number of patients presenting at the ED was “extremely large”.
He added that there were five fewer than the full roster of nurses and one doctors down on the full roster.
In addition, Mr Clarke said the situation at the ED on the night in question meant that while all patients in as severe a condition as Aoife should have been seen in less than 10 minutes, it would appear that it would have taken to more than 10 hours to see all “category 2 patients”.
He said a “very ad hoc system” was operating in which nurses could escalate patients up the list if they were concerned about their deteriorating condition.
He wrote: “The evidence suggests that the system, if it can be called that, was inadequate to deal with a very difficult situation where the large number of patients and limited number of nurses and doctors made the monitoring of patients with potentially deteriorating conditions much more difficult.”
Mr Clarke said the problems on the night “were undoubtedly significantly exacerbated by the chronic overcrowding” at the ED, adding that escalation protocols to alleviate the crowding were not operated until well into Sunday morning.
Mr Clarke also expressed thanks to Aoife’s parents for the “quiet dignity of their evidence”.
He said: “To lose a child is every parent’s nightmare. To lose a child in the fraught and traumatic circumstances of Aoife’s death is beyond understanding.
“To be present and feel powerless is unimaginable. All that can be said is that Aoife’s parents did everything possible to assist her. It is hard to imagine that it will ever be fully possible to get over the events of the third weekend of December, 2022.
“There are many steps to even some limited measure of closure. It is hoped that this report may be one step along that journey.”
HSE chief executive Bernard Gloster said: “This report has enabled us already to bring clarity to the concerns that arise from Aoife’s case based on a consideration of the evidence.
“It has given us a pathway to both learning and accountability. That accountability is and will be pursued fairly and appropriately in a confidential process.
“The learnings from the report and the recommendations are all being actively considered in the many aspects of improvement that are under way and indeed have relevance to assisting the overall patient safety agenda in all our settings.”