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Review over Aoife Johnston death to take around 8 weeks

The Health Service Executive has published the terms of reference for the independent investigation into the death of 16-year-old Aoife Johnston at University Hospital Limerick.

The review will be led by retired Chief Justice Frank Clarke and is due to be concluded in about eight weeks.

Aoife Johnston from Shannon, Co Clare, died after a 12-hour wait in the UHL emergency department on 19 December 2022.

She was diagnosed with bacterial meningitis and developed sepsis.

The terms of reference say that the independent probe will be an evidence-based report on the circumstances surrounding her death and the clinical and corporate governance of the hospital.

The new investigation follows a December 2023 systems analysis report received by the HSE into the case, details of which are set out in the terms of reference.

Overcrowding is endemic in UHL, an earlier review of the case found

Overcrowding is endemic in UHL, according to details of the earlier systems analysis review of the case, which was commissioned by the Clinical Director of the hospital.

The report found that the national guideline number 26 on sepsis management in adults and maternity was not followed on 17 December 2022, leading to a delay in sepsis care of 12 hours.

It found there was little apparent understanding of the risks and inefficiencies caused to patient care by a crowded environment.

The report said there were insufficient nursing staff to provide adequate monitoring and care to the patients in the emergency department.

There were also insufficient emergency medicine doctors and just one emergency consultant who is on call for the whole weekend.

It also found there was a high turnover of staff both nursing and emergency medicine non-consultant hospital doctors leading to low experience levels and low situational awareness.


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