COUNTY VIEW: Empty words and a tragic death

If vacuous commentary were an Olympic sport, then the Minister for Health would surely be an odds-on contender for the gold medal. In a profession where the ability to speak at length, without necessarily meaning anything, is a prerequisite, Mr Donnelly has learned his trade well, if his response to the Frank Clarke report is anything to go by.
Former Chief Justice Clarke had been tasked with the investigation into the death of Co Clare teen Aoife Johnston at University Hospital Limerick during Christmas week two years ago. The report is a painful catalogue of failings at the hospital, where the staff worked in conditions described as a war zone and which, most regrettably of all, led to an outcome that Mr Clarke said was ‘avoidable’.
The report itself paints a scathing picture of the chaotic conditions in the hospital’s ED on the night in question. Aoife Johnston was a Category 2 patient, which meant she should have been seen by a treating clinician inside ten minutes. But because 168 patients were on trolleys, and the staff complement was five nurses and one doctor less than that rostered, it would have taken ten hours to see all those in Category 2. In the case of Aoife Johnston, this meant it was 13 hours before the medical staff realised that she was at risk of sepsis, a condition that had already been flagged by her admitting GP and by at least one ED nurse. It was a delay that cost her life.
In any other comparable situation, such a report would signal a sweeping and prompt reform of a system that had failed so badly and with such a tragic outcome. The leader of the organisation would speedily initiate next-day reforms to ensure such a calamity could never happen again. Every possible strategy would be used to correct the abject failings of a system that, as Mr Clarke ominously warns, leaves patients at mortal risk unless corrective measures are taken.
However, the response of Mr Donnelly, the Minister for Health, was nothing short of tone deaf.
He would ask HIQA to ‘lead a review into urgent and emergency care capacity in the midwest region’, almost as if the Clarke report had not warned him of all he wanted to know already. Once again, the Minister had resorted to the tried and trusted kicking of the can further down the road to where the storm would have passed over and where, possibly, there might be some other occupant in the hot seat.
Nor did his ministerial wisdom end there. In a risible stating of the obvious, the Minister went on to explain that the Clarke report ‘had identified a number of factors that contributed to the delayed treatment leading to Aoife Johnston’s death, including unclear protocols, ad hoc systems, and poor internal communication’.
As a reassurance to the general public, the Minister’s contribution was akin to telling us that the day after Sunday was Monday, the bland chasing the obvious and delivered in the tone of a man who was himself but a disinterested observer.
The immediate cause of the Limerick tragedy was too many patients and too few staff, and in the panicked chaos of the hospital on that night, it was inevitable that mistakes would be made and that best practice would not, because it could not, be followed.
But nothing about the tragedy was unforeseen. Sixteen years earlier, a specially commissioned report had warned of the consequences of closing emergency units in smaller hospitals before capacity at Limerick was increased. The warning went unheeded, and the sad reality is that even now there appears to be a singular lack of urgency following the needless loss of a young life.