‘We hoped University Hospital Limerick would have learned lessons from our mother’s death’ – family of woman who died five years before Aoife Johnston

The unpublished investigation into the death of Brigid O’Loughlin (78) at UHL in October 2017 made more than 50 recommendations — including greater staff training in sepsis care.

Aoife Johnston (16) died in December 2022, and an investigation found she waited 12 hours in the hospital’s overcrowded emergency department to be treated for sepsis. The inquest into her death opens in Limerick tomorrow.

While sepsis was not a factor in Mrs O’Loughlin’s death, the unpublished report into her care at UHL said she had been diagnosed with suspect infection.

‘We believed they would translate into an improvement in patient safety’

However, it found that sepsis guidelines were “only partly adhered to” and there seemed to be “little awareness” of them among the clinical teams caring for her.

The report was provided to UHL management in 2019, almost four years before Aoife Johnston’s death. The review of Ms Johnston’s care found that national guidelines on sepsis management had not been followed in her case.

Mrs O’Loughlin’s daughters, Martina and Breeda, have called on the HSE to ensure recommendations made following investigations into patient deaths are fully implemented.

Apart from the loss suffered by the family, said Martina, “there is a much wider impact”.

“Our hope was that lessons would be learned from the failings identified in the system analysis review into our mother’s death. We believed they would translate into an improvement in patient safety.”

Mrs O’Loughlin, from Inch, Co Clare, died of bronchial pneumonia following emergency surgery for an abdominal condition that restricted blood flow to her small intestine, several weeks after attending UHL’s emergency department.

The hospital later apologised for deficits in her care and acknowledged that, though her condition was grave, there was the possibility she could have survived had the diagnosis been made earlier.

She had lived a full life, caring for her family and her community.

Mrs O’Loughlin met her husband Pat in the 1960s, and they enjoyed almost 50 years of married life together.

“She was proud of her birthplace,” said Martina. “She lived all her life in the same house in Inch, just outside Ennis, and she loved her home and garden.

“Our mother was a great cook and baker and loved to entertain the many callers to our home, who were never let out without a cup of tea.

“Mammy loved to knit, a skill she used every year to help the missions by knitting teddy bears for the local branch of Apostolic Work Society.

“She fundraised each year for the Irish Cancer Society, taking up church gate collections and selling daffodils for Daffodil Day which our father assisted her with.”

She was deeply involved in the community, travelling with her husband to Lourdes annually as part of the Killaloe Diocesan Pilgrimage. The couple had even intended to celebrate their golden wedding anniversary in Lourdes in June 2018.

In Mrs O’Loughlin’s case, the guidelines on sepsis were ‘only partly adhered to’

But in 2017, Mrs O’Loughlin became unwell.

She complained of chronic abdominal pain, vomiting and nausea over several months, and was treated at a private hospital where she was diagnosed with mesenteric ischemia.

But the diagnosis was not recorded in her discharge notes — and doctors at UHL told her inquest that they were unaware of the diagnosis when she attended them in August 2017, suffering from ongoing pain.

Mrs O’Loughlin was discharged that evening without being seen by a senior specialist.

The unpublished systems analysis review of her death found she was assessed in “suboptimal circumstances [in a corridor] that afforded neither privacy nor dignity”.

It added: “Even if admission had been advised, the patient would, more than likely, have experienced a further wait in the same sub-optimal environment.”

​When she returned to the emergency department days later on August 17, still in pain, she was assessed by a junior doctor and an infection was suspected.

The investigation found that once the infection was suspected, given her age and other factors, she should have started a “Sepsis 6 bundle”.

The procedure is a a set of six tasks which include taking bloods, monitoring urine and giving antibiotics, all to be completed within an hour to stem the infection and minimise any risks.

But in Mrs O’Loughlin’s case, the guidelines on sepsis were “only partly adhered to”, the report said.

Her blood cultures — which indicate the presence of infection — were not taken.

“Throughout the entries on August 17 there seems to be little awareness amongst the clinical teams of Sepsis 6 and thus poor adherence to its requirements,” the report stated.

She was not assessed by a senior surgical registrar until eight hours after she had arrived in the A&E, and six hours after she had a “working diagnosis” of intra-abdominal infection.

Mrs O’Loughlin had a CT scan but the problem, the report said, was that the scan did not take place sooner.

The review of her care found numerous ‘significant shortcomings’

“Earlier scanning may have led to earlier surgical intervention on August 17 which in turn may have improved the prognosis,” the report said.

Her condition deteriorated and the report linked this to “progressive sepsis”.

“More rapid management and adherence to Sepsis 6 may have reduced or avoided this scenario and allowed the patient to undergo surgery when the risks were lower,” the report said.

Mrs O’Loughlin underwent major surgery to her small bowel that night, as she was deemed to be critically ill.

She survived the operation, but remained unwell and in hospital for several more weeks until her death on October 4, 2017.

A post-mortem examination found the cause of death was bronchial pneumonia, following emergency surgery linked to mesenteric ischemia and other contributory medical factors.

Her family raised “very serious issues of concern” about her care. The systems analysis review of her care, provided to the family in 2019, found numerous “significant shortcomings”.

They included delays in getting a senior surgical assessment in A&E, and errors in her medication. These shortcomings were compounded by poor communication with the family, starting with the “failure to reach a shared understanding” of the gravity of her prognosis.

At the heart of several shortcomings, the report said, was the “striking” failure to adhere to or to implement national policies.

And while the review team acknowledged that improvements on sepsis management and documentation had been made after Mrs O’Loughlin’s death, they recommended that “all clinical staff in the emergency department should be familiar with and receive training in the National Clinical Guideline No 6, Sepsis management.”

It was one of more than 50 recommendations covering 14 areas including governance, practices in the A&E, and its handling of complaints.

‘He cried every day and died of a broken heart just 13 months after her death’

Other recommendations included an “urgent review” of national policies not adhered to at the hospital; a protocol for surgeons attending the emergency department; an “urgent” need for support mechanisms for staff; and the need for the HSE and UHL to review the wait times in the department.

Finally, Limerick’s hospital group management team was urged to “prepare an action plan, with clear timelines, for implementation of the recommendations in this report.”

Mrs O’Loughlin’s daughters reflected on these recommendations.

“We asked, through some of our local politicians, for evidence that the action plan was implemented and raised at national level,” Martina said.

“We’re still waiting to hear. It might have been implemented, but we’ve received no evidence that it was.

“We are raising this now to ensure that there will be improvements in the health service for the people of the Mid-West region.”

Martina believes the recommendations made in the report into the death of her mother at University Hospital Limerick are clearly still relevant today. Alas, her father died before the external review of his wife’s death was completed.

“He was left heartbroken, as where you saw one you saw the other, attending various functions and events.

“He cried every day and just could not pick up the pieces. He died of a broken heart just 13 months after her death. It left our family half the size it was just over a year before.”

Martina said her family was “torn apart” by the process of pursuing answers about her mother’s care.

“She was a wonderful mother to both of us — and her death has left a huge void in our lives.”