Family of Aoife Johnston not consulted on terms of reference of investigation into her death

Aoife Johnston, 16, died at UHL on December 19, 2022.

A lawyer representing the family of Aoife Johnston, who died in University Hospital Limerick (UHL) in December 2022, has said that the terms of reference for an investigation into her death were decided without input from the family.

Aoife, from Shannon, died at UHL on December 19, 2022 after waiting for 12 hours for treatment at its emergency department (ED). She was diagnosed with bacterial meningitis and later developed sepsis. She was 16 years old.

Earlier this week, the HSE announced the details of an independent review into the circumstances surrounding her death. It will be led by retired Chief Justice Frank Clarke and is due to be completed in around two months.

However, solicitor for the Johnston family, Damien Tansey, Senior Counsel and Senior Partner, Damien Tansey Solicitors, Sligo, has said that it is "a matter of great concern" that the terms of reference for the investigation were decided upon without input from the family. 

"There was absolutely no discussion or consultation with us, the legal representatives for the Johnson family, with the view to the makeup of those terms of reference," he said.

Mr Tansey said it was "entirely inappropriate" that the family effectively learned about the terms of the review from media reports.

Asked whether they would like the terms of reference changed, Mr Tansey said that, after consultation with the family, he and his colleagues, would be seeking to "add to and perhaps alter some of the terms of reference".

He said the family had also not been given an interim report into Aoife's case.

"Surely as interested parties, they should have been a given a copy of the interim report, and they should have been asked, like all of the other interested parties, for further observations-stroke-comments. That didn't happen."

The investigation into Aoife's death was announced after HSE chief executive Bernard Gloster received a systems analysis review (SAR) on her death which had been commissioned by the hospital’s chief clinical director.

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

It described overcrowding at the hospital as being endemic and also found that there was insufficient nursing staff to provide adequate care to patients at the UHL ED on the weekend of December 17, 2022.

There was also just one emergency consultant on call for the whole weekend, and only one clinical nurse facilitator for nurse training despite having a high turnover of nurses.

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."

'It beggars belief'

University Hospital Limerick. File Picture: Dan Linehan

Speaking on Morning Ireland on Thursday, Mr Tansey said one "cannot imagine" the difficulties that the Johnston family have faced since Aoife's death.

He said the family had been with Aoife for the 12 hours she waited at UHL's ED and that the experience was "haunting" them. 

Asked whether the case was likely to result in legal action, Mr Tansey confirmed that a number of actions had already been initiated.

"We have instituted proceedings on behalf of, and at the instigation of, and in the names of, each of the parents and the surviving children. The civil actions are well underway," he said.

Mr Tansey said the situation in the ED on the night of Aoife's death was "utterly chaotic" with "absolutely no leadership on the ground."

He also said Aoife's case bore similarities to the case of Lisa Niland, 19, who died at Sligo University Hospital in January 2017.

"Seven years later, if it would appear that no lessons have been learned and they go from crisis to crisis to crisis," he added.

"A tragedy occurs which attracts an enormous amount of media attention. Then it passes, a number of years go by, no changes are introduced and another tragedy occurs. It it just beggars belief."

An inquest into the death of Aoife Johnston is due to begin on April 21 in Limerick.