Investigation into death of Clare teen Aoife Johnston in Limerick to take eight weeks 

The independent will examine management of the hospital as well as the circumstances of Aoife Johnston's death

Aoife Johnston, 16, died from meningitis in UHL in 2022.

An investigation into the death of Aoife Johnston at University Hospital Limerick after a 12-hour delay in her care will examine management of the hospital as well as the circumstances of her death.

Terms of reference for the independent investigation were announced on Tuesday and indicate the review process will take only eight weeks. It is to be led by retired Chief Justice Frank Clarke.

This investigation was announced after HSE chief executive Bernard Gloster received a systems analysis review (SAR) on Ms Johnston’s death which had been commissioned by the hospital’s chief clinical director.

Ms Johnston, 16, died of bacterial meningitis on December 19, 2022, some two days after she presented at the hospital.

The review specifically said national guidelines for sepsis care were not followed, and that this led “to a delay in sepsis care of 12 hours”.

It said that despite high levels of overcrowding with patients on trolleys numbering between 42 and 55, the hospital’s escalation policy to deal with this was not followed.

Overall the review indicated: “There is little apparent understanding of the risks and inefficiencies caused to patient care by a crowded environment by the Hospital System”.

It said this refers to a lack of understanding of the impact on doctors’ ability to assess patients and the impact on nurses’ ability to provide safe care.

The report said there are “insufficient” consultants in emergency medicine and nurses to care for the number of patients attending the ED.

It notes specific shortages including only having one consultant on call over a full weekend and only one clinical nurse facilitator for nurse training despite having a high turnover of nurses.

It also said despite staff expressing sorrow and describing the gravity of this death to the review team, that “no evidence" was found of management seeking to identify and support staff.

Having received this systems analysis review, the HSE then decided an independent investigation was needed.

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.” Under the terms of reference, published on Tuesday, Chief Justice Clarke will report on the direct circumstances surrounding Ms Johnston’s death.

However, he will also report on “the clinical and corporate governance of University Hospital Limerick". He is expected to make recommendations on change.

Solicitor for the Johnston family, Damien Tansey, senior counsel and senior partner at Damien Tansey Solicitors, welcomed the HSE investigation when it was announced.

He told the Irish Examiner at the time the SAR “undoubtedly” indicated a further investigation was needed.

The family felt this report left "a lot of unanswered questions" which need to be addressed, he said.