Family of late Aoife Johnston 'profoundly disappointed' with report into her death

THE SOLICITOR for the family of the late Aoife Johnston has said they are profoundly disappointed with the report of the investigation into her death at University Hospital Limerick in 2022.

Speaking with RTÉ, solicitor, Damien Tansey, Senior Counsel, said a meeting with the family sought by the HSE Chief, Bernard Gloster, can not take place until the report by former Chief Justice Frank Clarke is published in full.

Aoife Johnston (16) from Shannon, Co Clare died at University Hospital Limerick in December 2022 following a 12-hour wait in the emergency department (ED). She was diagnosed with bacterial meningitis and later developed sepsis.

The family has given the HSE until the end of this week to publish the report unredacted. They receive the report a number of weeks ago.

The chief executive of UHL issued an instruction aimed at easing emergency department overcrowding two months before Aoife Johnston died but it was never clearly communicated to staff, according to the unpublished report. Colette Cowan told Mr Clarke’s inquiry into Aoife’s death that in October 2022 she had directed staff to move admitted patients out of the emergency department and on to wards, as reported by the Irish Independent.

Ms Cowan’s instruction was not implemented on the weekend of December 17 and 18, 2022, when Aoife died of untreated sepsis in a chronically overcrowded emergency department. The protocol was one of several decisions taken at executive level that didn't filter down to management, according to the report. Other protocols included filling out sepsis forms for patients who were suffering from suspected sepsis which was not adhered to in Aoife’s case.

The policy of moving patients on to wards to ease pressure in the emergency department, stopped on the advice of the HSE and reinstated two months prior to Aoife’s death is understood to be one of the key conflict grounds in Mr Clarke’s report.

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The report found that there was considerable confusion among staff about the protocol of placing trolleys on to wards and whether the practice was permitted or discouraged, according to sources.

Ms Cowan who has been on leave since January, was required to step aside from her role as part of the disciplinary process. Mr Gloster appointed former chief justice Frank Clarke to investigate Aoife’s death last December, after a HSE review found multiple “serious failings” and missed opportunities in an emergency department where overcrowding was “endemic”.

Mr Clarke’s report, which is said to have nearly 150 pages, made no adverse findings, did not resolve conflicting evidence and did not apportion blame. The report doesn't resolve the conflicting evidence between the staff on duty on the weekend of Aoife’s death, and deliberately avoids drawing conclusions from the evidence.

As reported by RTÉ, Mr Tansey said the restrictions imposed on Mr Justice Clarke by the HSE were most unsatisfactory and flew in the face of assurances given to the family by the HSE. The family had been assured the investigation would be unfettered, would be evidence driven and that Mr Justice Clarke could go wherever the evidence took him and that there would be accountability, he said.

Mr Tansey said the family were making no criticism of the former Chief Justice, but are very unhappy that his report was unable to make findings of fact, or attribute blame as they had put all their faith in the Clarke investigation.

A number of processes are under way in the HSE in relation to the issue. The HSE has said that at this point, there has been no adverse finding against any staff. It also said it was important that everyone's rights are respected.

Mr Gloster said the HSE hoped to publish the report or a publishable version of it and he wanted to meet with the family. In a statement, the HSE said Mr Gloster has said he will publish the report later this month, in an appropriate format, which must take into account the HSE's obligations to all parties involved and must respect the personal and sensitive data contained in the report.