Terms of reference published for investigation into death of teenage girl at busy hospital

THE Health Service Executive has published the terms of reference for the independent investigation into the death of Aoife Johnston at University Hospital Limerick.

The 16-year-old, from Shannon in Co. Clare passed away, in December 2022, after a 12-hour wait in the emergency department.

Last month, the HSE CEO Bernard Gloster announced he had asked retired High Court Judge and former Chief Justice Frank Clarke to carry out an investigation into Ms Johnston's death.

He did so shortly after he received the findings of an internal review which was carried out to establish the factual circumstances leading up to and surrounding the incident.

That report, details of which have been released this Tuesday night, identified several issues of concern at UHL which contributed to what happened after Aoife Johnston's presentation at the hospital.

It found that overcrowding is endemic in the emergency department and that the ‘boarding’ of admitted patients in the ED is a planned part of patient flow even though the specific staff to care for such patients have not yet been appointed.

The review found there is "little apparent understanding of the risks and inefficiencies caused to patient care by a crowded environment by the Hospital System, in terms of the impact on the Emergency medicine doctors assessing, and managing patients and the nursing staff’s ability to provide safe care".

General staffing shortages were identified and, in the specific case of Aoife Johnston, the review found that national guidelines regarding sepsis management were not followed and that the escalation protocol was "not not adhered to" on the weekend she presented despite the high numbers of patients awaiting inpatient beds.

Commenting following the publication of the terms of reference for Mr Justice Clarke's independent investigation, Mr 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.”

According to the terms of reference, the investigation is to be completed within eight weeks with a written report to be submitted to the HSE CEO.

Mr Justice Clarke will determine the methodology for his investigations and he may meet with any person or persons he deems appropriate and who he believes can assist with the investigation.

"The independent investigator shall make such enquiries, conduct such interviews, examine such documents, and engage in such correspondence as considered appropriate for the purpose of the investigation, " state the terms of reference which also confirm that all meetings will be recorded by a stenography company.

Mr Justice Clare will be provided with administrative support to assist his investigation and he may engage the services of experts with specialist expertise if he deems it appropriate to do so.