UHL ED Staff Unawareness Caused Aoife Johnston Tragedy
An investigation revealed that UHL ED staff unawareness caused the Aoife Johnston tragedy in 2022. The 16-year-old Aoife Johnston had a risk of sepsis which the emergency department (ED) staff of University Hospital Limerick (UHL) was unaware of.
With this, she was sent to the wrong section of ED alongside overcrowding that day. The forms for sepsis patients were not filled for her, hence, being sent to the incorrect department for treatment.
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Chief Justice Frank Clarke generated the report describing the serious consequences of the conflicts of evidence. The patient flow protocols occurring in the hospitals did not match with the other staff members as they were trying to alleviate the matter of overcrowding that day.
It was revealed that on the night of Aoife Johnston’s admission into the hospital, overcrowding was much worse than it normally used to be.
Chief Justice declared that all the pieces of evidence that gave rise to the Aoife Johnston tragedy were certainly avoidable.
The first ignorance occurred immediately after she was brought to the hospital. The initial assessment for Aoife Johnston was not conducted vigilantly and was delayed by one hour which could have revealed her risk of sepsis. Her GP sent her to the nurse who met her for her triage. The national protocol for hospitals requires the medical staff to carry out triage within the first hour.
Adding to the UHL ED staff awareness, Aoife was not taken to the Resus area where the forms for sepsis were managed. On the contrary, she was taken to Zone A, where there are no such forms available. Hence, no forms were filled for sepsis after bypassing the Resus area.
Mr Clarke confirmed that this was sheer ignorance of the staff as well as the doctors about her medical condition in detail.
However, there appeared a conflict between medical staff and nurses about asking the doctors to check Aoife as soon as possible since her condition started getting worse. The ED staff required the doctors to move her name up the waiting list as they became concerned.
Here, the chief justice was troubled about the patient emergency protocol which was not evidently stated in the document, which could have prevented overcrowding that day.
Chief Justice’s final words about UHL ED staff unawareness
According to the chief justice, the lack of clarity on these protocols created massive troubles that led to inappropriate diagnosis and eventually, the Aoife Johnston tragedy.
UHL ED staff unawareness was apparent and they did not have a clear understanding of the patient’s condition. However this shouldn’t have been the situation as nurse managers on the ground have the right to make decisions at senior management levels to avoid delays, the chief justice explained.
One more clarification on orders about moving the admitted patients to wards was missing between the night of 17 December and the morning of 18 December, which could have alleviated the pressure on ED staff.
Handling the capacity issue remained the prime highlight of the case. Why the thought of increasing beds at UHL did not occur to anyone’s mind that day, is a question yet to be answered since the other EDs in the region were closed.
After analysing all the proofs of the report, Mr Clarke was certain that none of the nurses or doctors were aware that Aoife Johnston suffered from sepsis and the suspected patient should have been treated according to her relevant department.
Mr Clarke said, “All of the evidence seems to me to confirm that these risks will not be further minimised without addressing the fundamental problem of overcrowding in ED”.
He declared the position of ED at UHL is crucial for handling overcrowding and overall capacity at the institute. Without careful management, UHL might remain under pressure and a “risk of recurrence will inevitably be present”, he concluded.
