Aoife died in ED ‘war zone’ with no chain of command

NOT for the first time in the grim history of dysfunctional Irish hospitals failing in their duty of care, the scene that gave rise to the tragic death of Aoife Johnston at University Hospital Limerick (UHL) has been likened to a war zone.

The inquest into the 16-yearold’s death from meningitis heard a tale that is by now depressingly familiar about our creaking yet lavishly funded hospital system.

The catalogue of disasters included an overcrowded emergency department (ED), with trolleys lined up so close together that they blocked doors and access to toilets and cubicles.

Patients lay on floors while attached to defibrillators; others were crammed into every available broom cupboard. In the packed waiting room, a growing backlog of more than 80 vulnerable and anxious patients languished without food or sleep for days before being seen.

Welcome to the most persistently overcrowded emergency department in the State, with a reputation so sickly that Limerick people often travel to Cork or Dublin rather than take their chances in it.

ON the weekend of Aoife’s death, conditions were worse than usual, with five nurses out of action and a spate of patients with fractures from the icy weather. The atmosphere became so febrile between patients desperate for medical attention and overstretched nurses that security guards had to be called to deal with the hostility.

In the chaos created by 191 patients – about one third of whom were considered dangerously ill – and a critical shortage of overwhelmed staff, nurses didn’t have time to update colleagues taking over from them at the end of their shift about the patients’ progress.

It was a missed opportunity to help the sickest patient in the emergency department, 16-yearold Aoife, who had a note from her GP diagnosing suspected sepsis but who wasn’t given treatment for 14 hours, and by then it was just too late to save her.

Comparing UHL’s Emergency Department to a war zone may help conjure up its mayhem and suffering but the metaphor collapses in regard to the strict chain of command and unquestioning authority that characterises most war zones.

In a war zone, the iron-clad discipline and tight control of the military ensures that everyone has a role and knows exactly who they are answerable to – even, or rather especially, when everything is falling apart.

The strict chain of command can help create order out of chaos, instil calm and resolve, and ultimately save the day.

But not only did UHL lack any cogent emergency plan on the night that schoolgirl Aoife vainly fought for her life, lying across two chairs in a storage cupboard while her frantic parents shouted for help, but orders and requests from two senior hospital figures designed to defuse the deteriorating situation were ignored.

At the inquest, clinical nurse manager Katherine Skelly described how, after surveying the crisis around her, she made an SOS call to a more senior nurse manager. Nurse Skelly told the inquest that she requested that trolleys be sent from the ED onto the wards. But she claimed this was not done.

The nurse – who has 23 years’ experience in healthcare and who resigned in the aftermath of the debacle – said that she told her superiors that the Emergency Department was ‘clinically unsafe’ and that the ‘risk to patient safety was at a level I had not encountered before’.

BUT there was a perhaps more serious breach in the supposed chain of command involving the manager-on-call, Fiona Steed. While the former hospital general manager – who now works for Health Minister Stephen Donnelly – told the coroner that she had no ‘executive powers to compel staff to do what she asked’, she claimed that she made several recommendations, including moving patients from trolleys in the Emergency Department into wards.

According to Ms Steed, she ‘wrongly and regrettably’ presumed her advice would be acted upon and consequently did not check with staff that they had done so.

The inquest also heard about how her suggestion that two emergency doctors be brought in to help panned out, and how her other recommendations were received.

Ms Steed’s evidence revealed a leadership that seemed quite ad hoc and casual, which staff adhered to when they could and otherwise ignored.

Her testimony about how her managerial role on the night meant that she was available to UHL staff by telephone, ‘to provide support and advice’ – but that it did not require her to attend the hospital in person – seems to confirm that the role was largely tokenistic.

She stressed that her job was ‘advisory’, and that she couldn’t order staff to make any clinical changes in the hospital, nor could she ‘compel’ consultants to come in when they were asked to and refused.

It’s logical that, in normal circumstances, administrators such as Ms Steed would have no say in clinical matters or indeed any sway over the consultant gods of the HSE. Healthcare is complex and hospitals are multilayered universes with disparate levels of autonomy throughout.

But as any nurse will tell you, hospitals also have a hierarchical culture with lots of kowtowing between specialists and heads of departments and their various underlings, and a top-tier board of management. In that sense, empowering managers to take control in an emergency should not be beyond any hospital.

Yet in UHL’s Emergency Department there was no one in charge on the night that Aoife Johnston met her agonising death.

War zone is a flattering term for what prevailed; anarchy would be more apposite.