HSE failures 'catastrophic' for Aoife Johnston - Gloster

The Chief Executive of the HSE has said "accountability is and will be pursued fairly and appropriately in a confidential process" following the death of Aoife Johnston at University Hospital Limerick (UHL).

Bernard Gloster said the HSE "failed Aoife and our failure has resulted in the most catastrophic consequences for her and her family".

He said the independent investigation, carried out by former Chief Justice Frank Clarke, was comprehensive and has given the HSE "a pathway to both learning and accountability".

In a statement, he said: "It is only right and proper that there is appropriate accountability based on evidence, facts and that it is lawful in how it is pursued".

"We now have that," he added.

16-year-old Aoife Johnston died at UHL on Monday 19 December 2022, two days after presenting at the emergency department with symptoms of suspected sepsis.

Mr Gloster said it is "also important to have learning to improve patient safety based on that same evidence".

"The learnings from the report and the recommendations are all being actively considered in the many aspects of improvement that are underway and indeed have relevance to assisting the overall patient safety agenda in all our settings."

He said the report has "enabled us already to bring clarity to the concerns that arise from Aoife's case based on a consideration of the evidence".

Mr Gloster added that had there been adverse findings against individuals, Chief Justice Clarke’s report could have been struck down by the courts.

However, it has given the HSE "a pathway to that accountability process and that has commenced".

Mr Gloster said: "When all is said and done today must be about Aoife and her family, recognising that all the reports and processes will not undo the harm caused to them."

"For that we are and must remain truly sorry. May she rest in peace."

The Irish Nurses and Midwives Organisation (INMO) welcomed the publication of the Clarke report.

In a statement, INMO General Secretary Phil Ní Sheaghdha said: "The INMO has been sounding the alarm on issues of patient safety due to unsafe staffing levels in UHL at local, regional, national and governmental levels as far back as 2016.

"Our members have long expressed deep … frustrations arising from the failure of the entire system to respond effectively, or at all, when clinical concerns were raised.

"Justice Clarke's report and the systems analysis review by medical and nursing experts commissioned by the HSE must be the catalyst for meaningful and lasting change in respect of overcrowding."

In a statement released this afternoon, Minister for Health Stephen Donnelly said: "HIQA has been asked to lead a review into urgent and emergency care capacity in the Midwest region, including to determine whether a second Emergency Department is required.

"Implementation of Mr Clarke's recommendations, as well as the actions and changes recommended by the HSE expert clinical review also published today, are important for the patients of the Midwest, as well as the staff in UHL, to rebuild confidence in the safety and quality of the care and services provided there," added Mr Donnelly.

Sinn Féin's spokesperson on health David Cullinane said: "The report is devastating in its critique of the closure of emergency departments in Ennis and Nenagh, a chronic lack of capacity at UHL, and a litany of failures in management and adherence to sepsis protocols.

"Aoife’s case and major population changes in the midwest over the last decade show that there is a compelling case for a second Model 3 hospital with an emergency department in the midwest.

"Emergency and urgent care services must keep pace with population changes, be clinically underpinned, and above all else, safe."

Additional reporting Cathy Halloran