A report into the death of Aoife Johnston at University Hospital Limerick has stated her death was "almost certainly avoidable".
Ms Johnston, 16, from Co Clare, died on December 19th 2022, after suffering from meningitis-related sepsis and was left for more than 16 hours without antibiotics.
The report by former chief Justice Frank Clarke into Ms Johnston’s death, published on Friday, said the on the night Ms Johnston was admitted to hospital, the emergency department was "under unusually severe pressure."
The report states "This investigation arises out of the tragic death of a sixteen-year-old girl in circumstances which, on the basis of all of the medical evidence, were almost certainly avoidable."
Ms Johnston was triaged as a category two patient, meaning she should have been seen by a treating clinician in 10 minutes.
“Having regard to the number of patients who were triaged in category two on the occasion in question and the number of doctors available, there was no reality to patients who were categorised in category two being seen by a clinician within anything remotely resembling that time frame.
The report also said that overcrowding at UHL played a significant factor to the events on December 17th and 18th.
"On December 17th 2022, presenting to triage between 00:00 hrs to 23.59, were two Category 1 patients; 94 Category 2 patients, 127 Category 3 patients and 14 Category 4 & 5 patients5. 42% of all presentations were thus Category 2. The national average is 22%.
"The evidence suggests that the ability of both doctors and nurses to do their job in an ordinary way is materially compromised by overcrowding and can be significantly compromised where that overcrowding is severe."
The report says the failure to identify Ms Johnston as a sepsis patient was also a factor of what went wrong at the time.
"The evidence suggests that none of the nurses or doctors who were working in relevant parts of the ED over the course of the night were aware that Aoife was a suspected sepsis patient.
"The fact that the sepsis form which ought to be prepared in respect of potential sepsis patients was not filled in Aoife’s case was undoubtedly a significant contributory factor to that lack of knowledge."
An inquest into Ms Johnston’s death earlier this year recorded a verdict of medical misadventure.
Since Ms Johnston's death, the report states that the emergency department is likely to be under pressure in the future.
"It seems likely that UHL ED will, unfortunately but regularly, be under pressure and, despite the improvements introduced since 2022, a risk of reoccurrence will inevitably be present."
As part of the reviews into the incident, the report recommends patients with serious illnesses in the emergency department but who do not arrive by ambulance should be seen quicker.
"Consideration should be given by the HSE to identifying whether there are ways in which patients who attend at the Emergency Department and who are potentially in need of urgent treatment, but who do not arrive by ambulance, can be assessed in triage more quickly, instead of having to wait in a queue system."
Mr Clarke said:“To lose a child is every parent’s nightmare. To lose a child in the fraught and traumatic circumstances of Aoife’s death is beyond understanding.
“To be present and feel powerless is unimaginable. All that can be said is that Aoife’s parents did everything possible to assist her. It is hard to imagine that it will ever be fully possible to get over the events of the third weekend of December, 2022.
“There are many steps to even some limited measure of closure. It is hoped that this report may be one step along that journey.”
INMO General Secretary Phil Ní Sheaghdha said: “Our thoughts are with Aoife Johnston’s parents, sisters, extended family and all who loved her following the tragic circumstances of her death.
“The INMO has long been to the fore of calling out the systemic problems that exist in University Hospital Limerick. The INMO has been sounding the alarm on issues of patient safety due to unsafe staffing levels in UHL at local, regional, national and governmental levels as far back as 2016.
“Our members have long expressed deep and have felt frustrations arising from the failure of the entire system to respond effectively, or at all, when clinical concerns were raised. Justice Clarke’s report and the systems analysis review by medical and nursing experts commissioned by the HSE must be the catalyst for meaningful and lasting change in respect of overcrowding.
“As we face into another winter of unknowns, overcrowding is beginning to ramp up in hospitals right across once again. The most effective way to minimise overcrowding is to adhere to the agreed de-escalation policy before the situation becomes unmanageable, this can only be done with sufficient, appropriate in-patient capacity and adequately staffed community services to which patients can be discharged.
“It is clear that safe nurse to patient staffing ratios must be underpinned by legislation. The Minister for Health and CEO of the HSE must now make this a priority.
“Clinical lessons from Justice Clarke’s report must be learned particularly ensuring that there is a sufficient number of both medical and nursing staff to provide safe care to a large volume of patients with complex care needs.
“Overcrowding in University Hospital Limerick has been out of control for far too long. While we recognise the challenges in addressing the embedded problems at the hospital, the commencement of internal process improvements and a full recalibration is needed on the Dooradoyle campus in order to change the approach to persistent overcrowding.
“It could not be clearer that the State’s in-patient bed capacity must be improved in tandem with safe levels of nurses and doctors to deliver care and treatment. The Government must now prioritise the delivery of additional bed capacity and begin recruiting nurses and midwives to ensure that patients will receive safe care.
"The Minister for Health and the Chief Executive of the Health Service Executive must outline what immediate steps are being taken in this regard and this must start with lifting the ban on recruitment and confirming that they will enact the Patient Safety (Licensing) Bill and give HIQA the jurisdiction to issue more than recommendations when safe nurse staffing is not in place.”
