Aoife Johnston did not have to die for us to learn that hospital overcrowding causes deaths

The retired Supreme Court judge Frank Clarke’s report on the death of Aoife Johnston clearly states that her tragic death in December 2022 was likely to have been avoidable. He found that there were several contributory factors that led to it, including the quality of a system for dealing with seriously ill and deteriorating patients, which he refers to as “ad hoc”, and the non-application of various protocols in situations where the emergency department is overcrowded. This was a regular occurrence at University Hospital Limerick (UHL), he states, and related to communication difficulties between senior nurse management and nurse managers on the floor in the emergency department.
Tellingly, he finishes his executive summary by referring to the fact that a very significant contributory factor in the overcrowding at the emergency department at UHL is the lack of bed capacity at the hospital. He specifically highlights a report for the HSE by Howarth Consulting in 2008 with respect to the projected number of beds the hospital would require in the context of the closure of the acute care beds at Ennis and Nenagh hospitals. He quotes a recommendation by the authors of that report in chapter six: “the overriding principle is that no acute service will be withdrawn from the current general hospitals until the regional ‘centre of excellence’ is resourced and ready to deliver that service with reference to international standards.”
The A&E departments were closed in 2009 well before UHL was adequately resourced to deal with the additional workload as a result of the closure of those A&E departments at Ennis and Nenagh. The question therefore arises as to whom made that decision to go against the recommendations of the expert Howarth report? Clarke states that the capacity issues at UHL were beyond the scope of his investigation but that such a decision deserved scrutiny by the relevant authorities.
His report does not talk about the impact that overcrowding in emergency department departments has on patients and staff – but a body of international research and reports does.
A Royal College of Emergency Physicians UK report in 2021 states that overcrowding leads to an increase in misdiagnoses and medical errors. It estimates that if 67 patients stay eight to 12 hours in an emergency department, one patient will experience avoidable harm. This and other international reports indicate that patient mortality rises with overcrowding. Sixteen-year-old Aoife died as a result of meningitis and sepsis at UHL and did not receive appropriate antibiotic therapy until 13½ hours after presentation, according to the report.
The Royal College and other international bodies have elucidated the causes of overcrowding in emergency departments. Their conclusions include the following.
First, and the most important, is inadequate hospital bed capacity. In 2021, an ESRI report stated that Ireland had the lowest number of inpatient beds per capita in the OECD and Europe. The Howarth report advised that UHL would need 676 acute inpatient beds based on population trends that have since been exceeded, and also recommended closure of the A&E departments at Ennis and Nenagh only after UHL had been properly resourced. In a report by the Health Information and Quality Authority (Hiqa) published in June 2022, the number of beds at the hospital in 2020 was just 432; 244 short of that recommended. Ninety-eight beds were added in late 2020 and early 2021 but this still meant the hospital was 147 beds short of the number recommended 15 years earlier.
In May 2023, the Minister for Health Stephen Donnelly announced the accelerated delivery of a further 96 beds.
Second, high bed occupancy rates are associated with overcrowding and hospital bed occupancy rates above 85 per cent are associated with increased risk to patient safety. Occupancy rates of 100 per cent have been associated with increased mortality in Denmark. UHL had occupancy rates of 109 per cent in early 2023 and consistently over 100 per cent in 2022.
The third factor was closure of A&E departments in a specific health region – the departments at Ennis and Nenagh were closed prematurely in April 2009 against the recommendations in the expert report for the HSE. Why did this happen and who made that decision? We are none the wiser. Was the decision made at regional level or at HSE board level? We do know that it had a detrimental impact on UHL and significantly contributed to overcrowding at the hospital A&E department, consistent with prior international reports.
The impact of overcrowding on emergency department staff is very significant. Staff working in such conditions suffer moral distress, a psychological state manifested by unease resulting from professionals’ inability to provide the most appropriate care. Over a period of time, this may give rise to moral injury that leads to impaired function or longer-term psychological harm. Some suffer burnout, a condition giving rise to depersonalisation, cynical or negative attitudes, and emotional exhaustion. In addition, overcrowding leads to increased turnover of staff and is a major reason for staff reductions in emergency departments. Both conditions were found in the HSE systems’ analysis report on the death of Aoife Johnston provided to Bernard Gloster, chief executive of the HSE, in December 2023. According to Clarke’s report, the emergency department at UHL was short five nurses and recruitment depended on employing those from other countries – another manifestation, surely, of a hospital system not fit for purpose?
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The HSE published a comprehensive guidance document on incident management and systems in October 2020, in which all factors that give rise to an error in the care of a patient are assessed, including active failures on behalf of individuals but also system factors, referred to as latent conditions. It states that if latent conditions are not dealt with, then preventing future errors will not be satisfactorily achieved. Clearly, 16 years after the expert report on the midwest region, the latent conditions persist and hence errors are likely to continue happening at UHL. On Sunday, the HSE chief executive said there continued to be a “risk” to life at UHL.
In these circumstances, one may well ask who is responsible for the overcrowding at UHL, given the delays in the much-needed beds? Will the HSE, government departments and politicians in Leinster House ever be held accountable for this state of affairs?
Dr John Barton is a retired physician and cardiologist at Portiuncula Hospital