A support team tasked with tackling overcrowding at University Hospital Limerick (UHL) said it is “unclear” who is operationally in charge of the healthcare facility on any given day.
On Friday, the Health Service Executive published two reports on the midwest hospital: one was an independent report by former chief justice Frank Clarke into the death of 16-year-old Aoife Johnston, while the other was led by the HSE’s national director of acute hospitals, Grace Rothwell, and focused on overcrowding in the midwest region.
Concerns have been raised about the safety of patients and staff due to the high number of patients waiting on trolleys and a corresponding delay in their receiving treatment.
In the Rothwell report, the support team examined the potential streaming options for patients in the hospital, such as being referred to the acute surgical assessment unit, the acute medical assessment unit and the geriatric emergency medicine unit.
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“Given the volume of admitted patients in the emergency department (overcrowding) and in the various assessment units the opportunity for these units to function is non-existent,” the report states.
In terms of staffing, there were “significant vacancies” at the clinical nurse manager level, which is “a particular concern”.
Trolleys were present in the “majority” of wards visited and the policy concerning their use was “unclear”, noted the report. It added that “the continued presence of ward trolleys places additional pressures on busy acute wards and their staff … Of particular concern is that it was not always known to ward staff how long a patient had been in the ED or another assessment unit as an admitted patient.”
The support team observed a “significant mismatch” at weekends, with far greater admissions than discharges.
“This ongoing cycle has resulted in an overcapacity build-up which the site is unable to eliminate given the constant high levels of demand and acuity,” it added.
This summer, the UL Hospital Group put a two-week “reset” in place, during which scheduled care was postponed to tackle a “historical backlog” of inpatients, before a gradual return of services.
The report on overcrowding was conducted by Ms Rothwell as well as director of nursing and integration at Waterford University Hospital Orla Kavanagh and retired emergency medicine consultant Fergal Hickey.
Separately, the report by the former chief Justice into the death of Co Clare teenager Ms Johnston highlighted several issues in the care she received.
According to that report, there were several systems and pathways of care in the hospital which appear to have been either in place and not implemented or not in place other than in an “ad hoc” way. These included the sepsis pathway and the escalation protocol for managing the capacity challenge.
Mr Clarke said decisions were taken by senior managers about how to reduce the overcrowding, but that “managers on the ground were not always as clear as to precisely what had been decided”.
The retired judge also highlighted capacity problems at the hospital and the impact the growing population and demand will have on services.
It makes 17 recommendations to the Health Service Executive, which HSE chief executive Bernard Gloster said would all be accepted.
Among the recommendations was that the hospital site should be assessed for further expansion and if it cannot be expanded to a “sufficient extent”, then another plan must be formulated.
Furthermore, communication systems at the hospital should be reviewed, and a review should take place of the co-ordination of the roles of doctors in the ED, in particular when the ED is busy and all doctors have many patients to attend to, he added.
The report does not make any adverse findings about any individuals, nor does it solve several conflicts of evidence, a situation the Johnston family have described as “disappointing”.
Last week, they called for the report to be published in full without redactions to “highlight its shortcomings”, according to the family’s solicitor, Damian Tansey. The published report has redacted the names of the clinicians involved.
However, Mr Gloster said there was still accountability arising from the report, and the “accountability has commenced” but it is “private to those individuals”.
“The question of accountability has to be addressed by me, it can’t be addressed by Mr Justice Clarke. If Mr Justice Clarke was capable of making adverse findings against individuals, number one his report would be outside his contractual process of rights and would likely stand struck down by the courts,” he said
“If his investigation was to find an adverse finding against an individual, that individual would have no chance of a fair disciplinary proceeding.”
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