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.”
