Who is running University Hospital Limerick and other questions arising from the Inquest into Aoife Johnston’s death

In my most recent blog in January 2024 – https://cantillons.com/blog/will-there-finally-be-accountability-in-the-hse/ –  I queried if there would be accountability in the HSE, finally.

My query arose having listened to an interview on Morning Ireland with Stephen Donnelly, our Minster for Health. He was asked by Rachel English why the family of the late Aoife Johnston (the 16 year old who tragically died in University Hospital Limerick (UHL)  in December 2022)  didn’t have any input into the Terms of Reference of an  investigation  to be conducted by former Chief Justice Frank Clarke  within the period of 8 weeks or as soon thereafter as practicable. (The Terms of Reference were published on the 2^nd January 2024, some 21 weeks ago. The written report on foot of the investigation is awaited).

Mr. Donnelly responded that in order to have a process whereby you could have accountability in the end, the advice that the HSE received was that no third parties could have input into the Terms of Reference. I have already stated that I do not agree with  this advice. Rachel English queried what exactly accountability meant; did it mean that someone might lose their job. Mr. Donnelly responded that if adverse findings are made then there are processes that might follow from the investigation. He advised that this is a new, different approach being adopted by the Chief Executive of the HSE, Mr. Bernard Gloster.

In the meantime, the Inquest into Aoife Johnston’s death has taken place.  Limerick Coroner John McNamara delivered his verdict of “medical misadventure” after four days of evidence.  Put simply, a death is categorised as medical misadventure where there is an unintended outcome of an action.  Mr McNamara  said that there were systemic failures, missed opportunities and communication breakdowns at UHL  during the period in which Aoife attended there prior to her death.

I did not attend the Inquest but am grateful for the excellent media reporting on the Inquest, and in particular to the Irish Times, from which I have extrapolated the following.

During the course of the evidence we heard  that  a  Senior House Officer, a Junior Doctor (who according to the Medical Council Register was registered as a doctor on the 12^th April 2022) was attempting to manage 191 patients in the ED on her own. We heard  that there was one ED Consultant on call for the relevant weekend. He gave evidence that  the ED was like an  aeroplane with passengers in every seat and blocking up the aisles. He described   the ED  as a “death trap” and that “Aoife Johnston had no chance.” He said that he did not accede to a request from a Clinical Nurse Manager to attend the ED on the Saturday evening the 17^th December 2022 (the evening Aoife attended) because he had to attend the hospital again on the Sunday morning.  He said that was not “Superman” and that he “was physically unable to come in”. He said that he was not made aware of Aoife’s case.

We heard  from  an Assistant Director of Nursing, who  said that she told the Clinical Nurse Manager to contact on-call consultants with concerns about overcrowding and that she was “not surprised, but disappointed” that the ED Consultant on call did not attend when requested.

We heard from  an “executive on call” that weekend, a General Nursing Manager, who gave evidence that she advised the Assistant Director of Nursing on a number of occasions to relieve capacity issues at the ED  and that this advice was not followed, for reasons that remain unclear.  She stated: “I wrongly and regrettably presumed that my advice had been followed”.   She also gave evidence that she had been informed of the ED Consultant’s refusal to attend the hospital on the evening of the 17^th December and that she “escalated” this by telling the Clinical Director of Medicine via text message but did not receive a reply that night. She stated that she did not have the power to compel consultants to come in.

There are many more questions than answers after this Inquest, to include who is running (or not running)  UHL?  Doctors  are regulated and are answerable to the Medical Council. Nurses  are  regulated and are answerable to the Nursing and Midwifery Board of Ireland.  Members of these two professions are clearly working in intolerable conditions in UHL.  To  my knowledge,  the health service managers are not answerable  to any regulatory authority. Why not?  Where is the accountability?

As a medical negligence lawyer for over 15 years, I have acted for many families of loved ones who have died in hospital.  The common thread in all cases is that they want to know what happened and why it happened.   Most have endeavoured to get the answers directly from the hospitals themselves but,  when stonewalled as they are invariably by the Risk Management Departments, they come to us . We regularly represent them at the Inquests into the death. Many are disappointed by the Inquest process as liability or fault  cannot be determined at an Inquest and they leave with more questions than answers as I was by the Inquest into Aoife Johnston’s death through no fault of the Coroner  I should say who conducted the process expertly.  We conduct investigations on behalf of the bereaved families.  We take up the medical records. We review them. We apply our expertise to ascertain if there were areas of concern in the care afforded and,  if so, we engage the appropriate experts to review the records and give opinions on the appropriateness of the care afforded and if not appropriate whether it caused and or contributed to the death of the loved one.  It is only  through the litigation process that our clients  get the answers they so desperately want. It may not be a perfect system but it works. Unfortunately the same cannot be said for our current health system.

In Aoife Johston’s case, the report following the  investigation by former Chief Justice Frank Clarke   is awaited and  according to a Statement of Stephen Donnelly  published on mygov.ie website  on the 25^th April 2024 and last updated on the 7^th May  he is “due to conclude his independent investigation in the coming weeks”.  Hopefully his  forthcoming report  will provide answers and accountability, and  lead to a better health system for all.  Thereby ensuring that some good will   come from “an unspeakable tragedy”, which is Aoife’s family’s fervent wish, according to the media reports.

Contact us at Cantillons Solicitors at Cork  +353 (0)21 4275673 or Dublin +353 (0)1 264 1802 or email info@cantillons.com  if you would like more information.

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