Report into Aoife Johnston death uncovers confusion among staff about overcrowding protocol
Family disappointed as report into A&E tragedy makes no adverse findings and does not apportion blame
Colette Cowan told former chief justice Frank Clarke’s inquiry into Aoife’s death that in October 2022 she had directed staff to move admitted patients out of the emergency department and on to wards.The practice is aimed at relieving pressure by removing patients from the overcrowded emergency environment, freeing up staff and space.It was stopped in July 2022 on the advice of the HSE’s performance management unit.Ms Cowan told Mr Clarke she had decided to reinstate the measure in October 2022, before the winter surge.UHL chief executive Colette Cowan. Photo: Press 22However, “no clear direction” was given to managers on the ground, Mr Clarke’s report noted.The report suggested nurses and staff were uncertain about the policy.It suggested there were differences among staff as to whether the practice was permitted, and Mr Clarke also noted “resistance” to the practice from nurses working on wards.The death of Aoife JohnstonColette Cowan’s instruction was not implemented on the weekend of December 17 and 18, 2022, when 16-year-old Aoife Johnston lay dying of untreated sepsis in a chronically overcrowded emergency department.The protocol was one of several decisions taken at executive level that did not filter down to management, according to the report.Other protocols included filling out sepsis forms for patients who were suffering from suspected sepsis — which was not adhered to in Aoife’s case — and escalating care for patients who were deteriorating in A&E.Nevertheless, Mr Clarke’s report, which is understood to run to almost 150 pages, made no adverse findings, did not resolve conflicting evidence and did not apportion blame.Aoife Johnston's family.The Johnston family were disappointed with the “utterly superficial” report, according to their solicitor Damien Tansey, who told RTÉ last week they want the unredacted report to be published as soon as possible.Mr Clarke’s report has, however, resulted in the HSE issuing disciplinary proceedings against Ms Cowan and two other senior figures, while three other senior staff have been notified of potential disciplinary proceedings.The chief executive, who has been on leave since January, was required to step aside from her role as part of the disciplinary process. HSE chief Bernard Gloster appointed former chief justice Frank Clarke to investigate Aoife’s death last December, after a HSE review found multiple “serious failings” and missed opportunities in an emergency department where overcrowding was “endemic”.It is understood Mr Clarke’s report highlighted the historic shortage of beds at UHL and the failure to ensure the facility was upgraded before emergency departments at smaller general hospitals in the region were closed.He called for an “urgent” review of the hospital site at Dooradoyle, warning it is “too small for all the additional beds required at the hospital”.University Hospital Limerick. Photo: Don MoloneyMr Clarke said that the hospital needed 183 beds by the end of 2027 and cited a Deloitte report that said 302 beds will be required by the end of 2036.Research should be “urgently carried out” to identify the limitations of the Dooradoyle site.He also commented on the decision to close the emergency departments of the smaller general hospitals before University Hospital Limerick was upgraded with extra bed capacity.Mr Clarke said a 2008 report by Horwath Consulting was “absolutely clear that emergency departments in the midwest outside of Dooradoyle should not be closed until Dooradoyle was upgraded. That did not happen.”Only 98 extra beds have been provided to date, with an additional 16 beds under construction, “together with a further net 71 beds due during 2025”, Mr Clarke said in his report.He added: “The situation today is that UHL is still well short of the number of beds recommended by Horwath as being required to allow all emergency departments in the midwest to be relocated to Dooradoyle.”The policy of moving patients on to wards to ease pressure in the emergency department — scrapped on the advice of the HSE and reinstated two months prior to Aoife’s death — is understood to be one of the key conflict grounds in Mr Clarke’s report.Aoife Johnston lying on a makeshift bed in UHL's A&E department hours before she diedThe report uncovered considerable confusion among staff about the protocol of placing trolleys on to wards and whether the practice was permitted or discouraged, according to sources. UHL’s senior management stopped the practice in July 2022, after the intervention of the HSE’s performance management unit which advised against it. The specialist unit was sent in to support and advise on emergency department overcrowding.Between July and October 2022, no patients on trolleys were moved from A&E on to wards.However, Ms Cowan told Mr Clarke she had reinstated the practice on October 24 as the hospital was heading into the winter period.The INMO objected, according to the report. The union wrote to Ms Cowan to complain about this “retrograde step” of placing additional patient trolleys on corridors “when a review group appointed by the HSE eradicated this practice from this hospital”.The letter from the INMO added: “The action taken this weekend by management is viewed as unsafe, counterproductive to the patient flow processes that were progressing well while the review team were on site for a shorter period of time.”HSE chief Bernard Gloster (left) appointed former chief justice Frank Clarke to conduct investigation into the death of Aoife JohnstonUltimately, this instruction to reinstate placing trolleys on wards was not passed down to staff and managers, according to Mr Clarke.It is understood he heard conflicting views from staff on their understanding of the status of the protocol and whether or not it was acceptable practice.It is believed Mr Clarke examined in some detail the conflicting views of nurses and executive staff on duty on the weekend that Aoife died but reached no conclusions.The conflict was first aired at the inquest into Aoife Johnston’s death in April.Katherine Skelly, the clinical nurse manager in A&E on the night the teenager presented with her parents, told the inquest the hospital was overwhelmed because of an influx of acutely ill patients with multiple fractures sustained in the severe weather conditions.Ms Skelly described the emergency department as akin to a “war zone”, that it was “clinically unsafe” for patients and constituted a “major incident”.She said she asked repeatedly for patients to be moved out of A&E and onto wards.Fiona Steed, the “executive on call” on the weekend Aoife died but now chief health and social care professional at the Department of Health, told the inquest she gave advice to the senior assistant director of nursing, Patricia Donovan, to move trolleys on to wards.She said she “wrongly presumed” her advice would be followed. Assistant director of nursing Patricia Donovan told the inquest she passed on the instruction to nurse Tara Shine, but she could not find patients suitable for moving.A second senior nurse manager told the inquest that Ms Skelly was asked to “sit down” with the bed manager and identify suitable patients.Aoife JohnstonMs Skelly told the inquest this never happened, the instruction was never given, and she was still phoning management at 3.45am “asking for trolleys to go on wards”.Ms Shine, who did not testify at Aoife’s inquest, is understood to have told the inquiry she received no instruction to move patients on to wards.Mr Clarke’s report does not resolve the conflicting evidence between the staff on duty on the weekend of Aoife’s death, and deliberately avoids drawing conclusions from the evidence.The judge said he was contacted by legal counsel for HSE chief executive Bernard Gloster before he started his investigation.Following that contact, he determined that it was “not within the scope of this investigation to resolve disputed issues of fact. Rather to the extent that any such issues arise, the report simply records the competing evidence.”However, Mr Clarke said this “does not mean recommendations may not, to a greater or lesser extent, have a potential impact, in general terms, on those involved”.The HSE declined to comment on Mr Clarke’s report.The Department of Health said the minister, Stephen Donnelly, has asked Hiqa to assess capacity in the midwest as a result of ongoing issues at UHL’s emergency department.Aoife Johnston was 16 when she died from sepsis in December 2022Timeline of a tragedyDecember 17, 2022 5.40pm: Aoife (16), a Leaving Cert student from Shannon, Co Clare, presents at UHL’s A&E with suspected sepsis. 7.15pm: Aoife is triaged as query sepsis and left to wait.December 18, 2022 5.45am: Aoife is assessed and prescribed antibiotics. 7.15am: Aoife receives antibiotics and is left on a trolley. 8am: Aoife’s father roars for help, a nurse finds Aoife “distressed, tearful and agitated” and her limbs moving involuntarily. She is intubated and transfers to ICU.December 19, 2022 3.31pm: Aoife dies from purulent meningitis.December 2023 Aoife’s family receive a damning internal review of her care highlighting missed opportunities and breach of national sepsis guidelines.December 18, 2023 HSE chief Bernard Gloster appoints former chief justice Frank Clarke to investigate, citing need for accountability.April 26, 2024 Inquest rules Aoife’s death a medical misadventure.July 2024 Frank Clarke submits his report to Mr Gloster who begins a disciplinary process against several senior staff.August 2024 Johnston family informs HSE of their “profound disappointment” with a report that fails to draw adverse conclusions or resolve conflicts around Aoife’s death.
