When news emerged that 16-year-old Aoife Johnston died in University Hospital Limerick in December 2022, there was public outrage.
Known as the most overcrowded hospital in the State, it has been described as being “like a war zone” by clinicians who worked the weekend the Co Clare teenager died.
The independent report on her death by former chief justice Frank Clarke, published on Friday, highlighted a litany of issues throughout her time in the hospital.
Triaged as a category two patient, she should have been seen within 10 minutes. Clarke said due to staffing and demand, “it would have taken over 10 hours (as opposed to 10 minutes) to see all category two patients”.
Delays were a significant problem. Johnston was waiting more than 13½ hours between her arrival at the hospital and receiving treatment.
Even when she was prescribed antibiotics, more than an hour elapsed before they were administered to her.
Protocols around sepsis were not followed. Unlike most patients who are considered to be at risk of sepsis, was not brought to the Resus area after triage and was instead brought to zone A in the ED due to overcrowding.
As a result of this, sepsis forms were not filled out, which “undoubtedly contributed” to the fact that nurses and doctors in the ED were not aware Johnston had been identified by a GP and a nurse as being at risk of sepsis.
The difficulties within the hospital are laid bare in the report. The word risk is included in the report 58 times, “ad hoc” is used 16, while “challenging” is used to describe the conditions and circumstances on the night in question 23 times.
This is just one individual story. But it is indicative of a much bigger problem. UHL has long been flagged as the problem child of the health service. The Government often says it has increased funding dramatically, but issues around overcrowding and staffing levels persist.
This is something highlighted clearly in the Clarke report. There was a “significant” shortage of staff on the night in which Johnston sought care. There were five fewer nurses than required and one less doctor.
“The chances of delay, such as occurred in this case, in the administration of an urgently needed prescribed medication when clinicians and nurses are working under considerable pressure are self-evident,” the report said.
But perhaps the most prominent difficulty is capacity which is a well-touted problem and Clarke focused in on the pathways that lead the hospital to its current situation.
Other EDs in the midwest were closed in 2009, resulting in all serious emergency patients being directed towards UHL in Dooradoyle.
A 2008 document, known as the Horwath report, noted that the closure of the other EDs should not occur until the capacity of Dooradoyle was increased.
“While there are further expansion projects in the pipeline, the fact remains that, even today, some fifteen years later, the capacity of Dooradoyle is significantly below that recommended by the Horwath Report as a pre-condition to closing the other emergency departments in the Midwest Region,” stated the report.
“Indeed, given the increase in demand on acute services in the Midwest Region since the time of the Horwath Report, even those estimates as to the increases needed to facilitate concentration in Dooradoyle are likely to be out of date.”
It is no wonder, then, that overcrowding persists in the hospital. On Friday, there were 45 people on trolleys in UHL, with another 45 in surge capacity — and this is in September before the typical winter wave of respiratory illnesses arrives.
But what does that mean for the safety of patients and staff who attend the hospital? Though Clarke acknowledges improvements in the systems over the past two years, “unless and until” the problem of bed shortages is addressed, he said it is likely “a risk of reoccurrence will inevitably be present”.
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