Everybody needs to 'look in the mirror and necessitate urgent change' at University Hospital Limerick, a patient advocate has said.
It comes after a verdict of medical misadventure was returned on Thursday at the inquest into Aoife Johnston's death at the hospital.
The 16-year-old died at the hospital on December 19th 2022.
She presented at the facility with an on-call GP referral which queried sepsis; however she wasn't seen by a doctor for 12 hours.
On Newstalk Breakfast, Irish Patients Association Director Stephen McMahon questioned if changes had been made.
"The findings of it are tragic, certainly the system must learn from that," he said.
"But the questions still arise as to has everything been done in University Hospital Limerick?
There are a number of other inquiries going on and we've heard in the last 24 hours that this must be a major turning point".
'Preventable funerals'
Mr McMahon said such tragedies can bring about positive changes.
"The maxum of the Irish Patients Association is that change and reform in our healthcare system should not be preceded by preventable funerals and injuries to patients," he said.
"It's only out of such tragedies that these changes actually start to happen.
"A number of years ago the Irish Patients Association tried to get access to a review by Professor Keane which included Limerick University Hospital.
"The significance of this report is that the HSE had said that the recommendations had been superseded by changes in the way things were done.
"But the Department of Health itself had reservations as to the claims".
'Dangerous levels'
Mr McMahon said work has got back to "normal" since COVID but University Hospital Limerick "is overcrowded to dangerous levels".
"It's more than just simply putting money into the system but we have the situation today of these tragedies and there have been a number of them," he said.
"The Irish Association for Emergency Medicine has regularly highlighted the fact that overcrowding can lead to increased mortality."
Mr McMahon said everyone involved needs to implement changes.
"Everybody needs to look in the mirror and put their hands up and to necessitate urgent change from the interests of patients," he added.
During the hearing a doctor who treated Aoife before her death described University Hospital Limerick as a 'war-zone'.
