HSE apologises to family of 16-year-old for 'serious failings' in her care at Limerick hospital

Hse Apologises To Family Of 16-Year-Old For 'Serious Failings' In Her Care At Limerick Hospital
A damning internal review of the circumstances of the death of Aoife Johnston, (16), from Shannon, Co Clare, was provided to her family last week, it emerged on Sunday. Photo: PA Images
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David Raleigh

The HSE has apologised to the family of a teenager who died of meningitis in University Hospital Limerick, for the “serious failings in the care” provided to the girl at the hospital.

A damning internal review of the circumstances of the death of Aoife Johnston, (16), from Shannon, Co Clare, was provided to her family last week, it emerged on Sunday.


The report found Aoife waited 12 hours in UHL’s severely overcrowded emergency department and was not treated for sepsis until it was too late.

She was not given the care she required despite her family desperately flagging her deteriorating condition.

The review found that delays in her treatment breached national guidelines on sepsis management.

She died of bacterial meningitis in UHL on December 19th, 2022, two days after she presented at the hospital.


The unpublished report, which was commissioned by UHL last January - and was supposed to be completed by last March - was given to Aoife’s family last week.

Aoife’s death occurred during severe overcrowding in UHL.

The review is also understood to have found that there was a significant shortage of staff over the weekend in question, without a contingency plan to deal with the pressures on the hospital triggered after a severe weather event which added numbers of emergency patients.

UHL’s escalation protocol was not adhered to, despite the number of patients waiting, and, the executive management team appeared to have “little understanding” of the risks to patient care caused by an overcrowded environment, in terms of the impact on assessing and managing patients and the nursing team’s ability to provide safe care, it is understood.


UL Hospital Group chief executive, Colette Cowan, has sent a letter of apology to Aoife’s family for the hospital’s failings in her care.

The UL Hospitals Group was not available for comment, but a HSE spokesperson issued a statement which said: “We have this week shared with the family the review into the tragic death of their daughter.

"We have apologised to them for the serious failings in the care we provided to their daughter which have been identified in the review.”

“The review has been referred to the Coroner who has yet to make a determination in the case.”


“The chief exectuive of the HSE, Mr Bernard Gloster received the review in recent days and is considering the very serious and significant issues that arise. He is aware that ULHG have offered a sincere apology for the failings in the care we provided to this girl which have been identified by the review.”

They said Mr Gloster, a native of Limerick, was “willing to meet the family privately should they wish to do so but it is a matter for the family to decide if and when they might like to do this”.

“Out of respect for the family, and to give the Coroner time to consider the matter, we will not be commenting further on the report at this time. We wish to extend our sincere condolences to the family following their devastating loss.”

The review into the circumstances of Aoife’s death was commissioned by Prof Brian Lenehan, Chief Clinical Director, UL Hospitals Group, and completed by an expert HSE team external to UL Hospitals Group under the HSE Incident Management Framework.


Aoife’s death sparked political and public protests nationwide over chronic overcrowding in emergency departments.

However, despite continued investment at UHL, it remains the most overcrowded hospital in the country despite several measures introduced by management to mitigate the problem of overcrowding.

Many in the region blame the overcrowding in Limerick on a 2009 government policy decision to streamline all 24-hour accident and emergency units across Limerick, Clare and north Tipperary to UHL.

During a visit to UHL last February, the Taoiseach, Leo Varadkar, said to reopen the 24-hour EDs across the region would be “impossible”.

However, less than an hour later when he met families of patients who had died in UHL against a backdrop of intense overcrowding, Mr Varadkar said he was not ruling it in or out.

When asked for clarification on the issue at the time, a spokesman for the Taoiseach said that while reopening the 24-hour ED units was “not the current plan”, that, “the Taoiseach had indicated, nothing is off the table until discussions have taken place with the incoming chief executive of the HSE and the Minister for Health”.

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