Aoife Johnston: Health Minister urged to “dig deeper” into report on death of teenager at UHL

Aoife, from Shannon, Co Clare, died of meningitis on December 19, 2022 at UHL after she was left for more than 13 hours without antibiotics - a “vital” treatment to help save her life

Health Minister Stephen Donnelly has been urged to “dig deeper” into the report of Aoife Johnston’s death to prevent a repeat in the future.

Willie O’Dea TD called for action after it found the 16-year-old’s death was avoidable, and warned it could happen again.

Campaign group Friends of Ennis Hospital said: “Our children should not be dying of treatable conditions. Aoife’s death must be a watershed moment.”

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Limerick representative Mr O’Dea said described the harrowing 247-page Clarke report as “damning” and the level of overcrowding at University Hospital Limerick unacceptable.

Aoife died of meningitis, brought on by sepsis, after she was left for 13 and a half hours without vital antibiotics.

Up to 191 patients were in the ED on the night Aoife was admitted, with 19 nurses on duty and one clinical nurse in charge.

Aoife was triaged as a category 2 patient, meaning she should have been given life-saving medicine within ten minutes of arrival at the hospital.

But she was sent to the wrong area and left vomiting green fluid on a chair and trolley, and did not receive antibiotics until it was too late.

Medical staff were unaware she was a sepsis patient because she was not brought to Resus meaning the relevant form was not filled out.

Former Chief Justice Frank Clarke’s report concluded that Aoife’s death “was almost certainly avoidable”.

He issued a stark warning that unless chronic overcrowding at UHL is tackled a similar tragedy could happen in the future.

HSE head Bernard Gloster issued an apology to Aoife’s parents after the former judge’s report exposed care failings at the hospital.

Mr Gloster said on Friday: “We failed Aoife and our failure has resulted in the most catastrophic consequences for her and her family.”

Last night Friends of Ennis Hospital called for senior hospital staff to be held accountable for the systemic failures on the night Aoife died.

In a statement issued yesterday it said: “The Clarke report into the death of Aoife Johnston is harrowing.

“It shows systems failures across several layers of medical and management staff in UHL caused the ‘almost certainly avoidable’ death of a 16 year old child.

“Our hearts break all over again for her family, friends and loved ones as Justice Clarke lays out the failures in her care from the moment of admission.

“To say that ED in UHL on the night of December 17, 2022 was ‘operating’ more by good luck than good guidance is not an exaggeration.”

The Clarke report highlights the gross overcrowding on the night Aoife presented, when there were 168 patients on trolleys at UHL.

The FEH statement continued: “Aoife Johnston was failed by the HSE. She was failed by systems that are not fit for purpose.

“She was failed by management who told the Dail Joint Committee on Health a mere three months previously (September 2022) that ‘UHL continues to provide safe, quality services for its patients’.

“And she was failed by staff who are now facing disciplinary proceedings as a result of her death.

“Aoife Johnston was also failed by us, both the public and the health campaigners who did not shout loud enough, or long enough or often enough about the failures we saw and continue to see in UHL.

“Our children should not be dying of treatable conditions in our acute hospitals in a first world country in the 21st century.

“Aoife’s death must be a watershed moment for University Hospital Limerick.”

An inquest into Aoife’s death earlier this year recorded a verdict of medical misadventure.

The Johnston family, who waived anonymity so the report could be published, expressed disappointment that it did not name staff involved or resolve conflicting accounts.

The Clarke report makes 17 recommendations aimed at improving patient care in UHL’s emergency department, in particular with cases of sepsis.

In a statement on Friday Minister Donnelly said work was “now under way” in the HSE to implement the report’s recommendations.

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