The head of the HSE has said that six people are facing a disciplinary process in relation to Aoife Johnston as he apologised to the family again for failings in the teenager’s care.
Bernard Gloster said there was still “a risk” of reoccurrence at University Hospital Limerick’s (UHL) emergency department, but the risk was now reduced and said the aim was to make the hospital “safer”.
An independent report found that a “grossly overcrowded” emergency department and “lack of clarity” on sepsis protocols were among the factors ahead of Aoife’s death at UHL two years ago.
The 16-year-old died at the hospital after waiting for 12 hours to be assessed for suspected sepsis.
Aoife presented to the hospital’s emergency department (ED) on the evening of Saturday, December 17th, 2022 following a referral from an out-of-hours GP service which had queried the possibility of sepsis.
She was not administered the appropriate sepsis bundle of medication until 13 hours later, between 7.15am and 7.20am; protocols on sepsis suggest that treatment should take place within one hour.
The HSE published a report on Friday written by former chief justice Frank Clarke, who described the circumstances around her death as “almost certainly avoidable”.
Mr Justice Clarke’s report also said that unless capacity issues at UHL’s emergency department are addressed, and despite improvements made since 2022, “a risk of reoccurrence will inevitably be present”.
On Sunday, Mr Gloster apologised to the Johnston family and said he can “only imagine” what they are going through.
“We can never tire of saying we failed Aoife, we failed her badly. Our failure caused her death and that has led to the devastation that her family are now left with,” he told RTÉ Radio’s This Week programme.
“It is important to start any commentary by recognising that, by restating that and by that motivating us to do what we can now to ensure the system is better than that.”
Mr Gloster also addressed concerns raised by the Johnston family’s solicitor, who said the family wanted people to be held accountable for failings in their daughter’s care and were unhappy that the report did not have adverse findings.
He said that four members of staff were on administrative leave from their roles and that others are facing disciplinary investigation.
“At this point in time six people are the subject of various considerations within the disciplinary process.”
He said he will be able to confirm when the process is concluded, whether there were findings against people and whether sanctions were applied – but he said he would not be able to confirm who is the subject of those processes.
Damien Tansey, solicitor for the Johnston family, said that when wrongdoing is exposed, “part of the sanction” is public disclosure.
“Aoife Johnston and the family are in the glare of publicity since her death and that continues. And yet the people who caused it are entitled, according to the HSE, to anonymity.”
Mr Gloster said: “People can have no doubt that accountability is being pursued here, but this is being pursued lawfully and appropriately and fairly, and lest there be any doubt, everything that Frank Clarke has said to me has been accepted, including all of the failures that you have pointed to.”
The HSE chief said that if Mr Justice Clarke were able to make adverse findings, the report would not have been available for “a very, very, very long time”.
Mr Gloster said he did not intend to give the impression to the Johnston family during a meeting in previous months that Mr Clarke could make adverse findings.
He said: “Had he chosen to make adverse findings in respect of any individual, there’s a critical chance his report would have been able to be struck down in the courts were it challenged, that’s the first thing.
“The second thing is I would ask anyone to reflect on the fact that were the former chief justice of Ireland allowed to make a finding against you in a civil process and a civil report, what chance would anybody stand of a fair hearing under the disciplinary procedures in their contract – and the answer to that is they wouldn’t.”
He said the choice was not a “binary” one of either recognising the trauma suffered by the Johnston family or to operate lawfully.
Asked who made the decision on whether adverse findings could be made as part of the independent report, Mr Gloster said that was clear from the terms of reference.
“If people wanted and desired accountability in our public services, be it in this case or any other, that accountability if it is not pursued lawfully and appropriately, it doesn’t stand up, it can’t happen.”
Mr Gloster said he made it clear on several occasions before the report was concluded that the issue of accountability rests with him as head of the HSE.
He said that he did not believe a statutory inquiry, as now requested by the Johnston family, would reveal “anything different or any greater accountability” than Mr Justice Clarke’s probe already had.
“All of the reports in the world are not going to change the harm that was done to Aoife’s family as a result of the failing here,” he said.
