AN independent investigation into the death of teenager Aoife Johnston from sepsis after 12 hours in the emergency department (ED) of University Hospital Limerick (UHL) will be a no-holds-barred probe that is set to be completed within eight weeks.
That’s according to the terms of reference for the investigation – which is to be led by retired supreme court judge Frank Clarke – published by the HSE this week.
The announcement comes after the HSE’s own Systems Analysis Report (SAR), published in late December, found repeated missed opportunities to treat the young woman and to deal with her condition according to the national guidelines for sepsis management.
Details of the remit of the investigation into the 16-year-old’s death in December 2022 come as a chilling account of what is contained in the unpublished HSE report, revealed by the Sunday Independent.
The report states that one of the last memories Ms Johnston’s parents have of their child is having to hold her down so that treatment could be administered.
The report records how Ms Johnston’s father gave a “roar of distress”, pleading for his child to be assessed by a doctor, while even the other patients in the ED were asking that something be done for the young girl from Shannon in County Clare.
From a copy of the report seen by Sunday Independent, it was outlined how a single nurse was left to attend to up to 67 acutely unwell patients, including Ms Johnston, in one zone of the emergency department.
Despite repeated concerns about the Shannon girl’s condition being raised by a senior nurse with a number of doctors, all of the doctors said they were too busy dealing with other acutely ill patients to come and see her until much later in her time in the ED.
It has been reported that there was just one emergency medicine consultant on call for the whole weekend.
The report states that Aoife and her family were let down by the “systems” in the emergency department, allowing a Category 2 patient with a “possible sepsis” who should have been seen within 15 minutes to wait 12 hours for a medical review, by which time it was too late.
Publishing the terms of reference for the independent investigation, the HSE said that the retired judge will have access to all staff involved in the case and all records of the late student’s treatment, as well as access to records of activities in the ED during her time there.
He will also be free to call in outside specialist expertise where necessary.
“The Independent Investigator is free to seek any information and to raise any issue which they consider relevant to the investigation,” the remit states.
“Refusal or failure to co-operate by any individual will not prevent the Independent Investigator producing a written report at the conclusion of the investigation based on the information available to them at the time.”
The investigator has been asked to produce a written report, which will be submitted directly to the HSE CEO Bernard Gloster.
The terms of reference do not state whether the findings of the independent investigation will be made public.
The outcome and recommendations contained in the report from the investigation may also be used to support further procedures or law suits, the HSE says.
The CEO of the UL Hospitals Group, Colette Cowan, and the HSE have apologised to Ms Johnston’s family. Her sister, Meagan Johnston, is suing the HSE on behalf of their family through solicitor Damien Tansey SC.
Commenting on the process HSE CEO Bernard Gloster said: “The scope of the Independent Investigation is to provide an evidence-based report on the circumstances surrounding the death of Aoife and the clinical and corporate governance of University Hospital Limerick which led to the conclusions set out in the previous systems analysis report. The judge has been asked to make any recommendations as he sees fit and to report directly to me.”
Chief Justice Frank Clarke bowed out as a Supreme Court judge after a law career which spanned 48 years, 17 years serving as a judge and the last four as Chief Justice.
