*Aoife Johnston.
A VERDICT of medical misadventure was returned following the four-day inquest into the death of Clare teenager Aoife Johnston.
Aoife died at the age of sixteen from meningitis at University Hospital Limerick on December 19th 2022.
She had presented at UHL two days previous with suspected sepsis. In the hospital, she faced a lengthy wait for treatment despite displaying severe symptoms. The teenager ultimately waited more than 15 hours to receive antibiotics, which would likely have saved her, the inquest heard.
The inquest into Johnston’s death took place over four days at Kilmallock Courthouse in Co Limerick. Aoife’s parents, James and Carol, and sisters, Meagan and Kate, fought back tears as the verdict was returned by Limerick Coroner John McNamara, whose bench had framed photos of Aoife on either side at the request of the Johnston family. The family had asked for a verdict of death by medical misadventure, with both the UHL and the HSE raising no objection.
Mr McNamara said Aoife’s death was “truly tragic” – and cited overcrowding at UHL as an issue of major concern. “I am concerned about the overcrowding as a native of Limerick. I accept that changes have been implemented. However, for the formality of the record, I want to endorse wholeheartedly the recommendations of the Hamilton Report (into UHL’s emergency department),” he said.
He said the verdict of death by medical misadventure was the only one that could be recorded. “There were systemic failures, there were missed opportunities and there were communication breakdowns throughout. Aoife should have been treated in a timely manner,” he said.
“Time was of the essence and there was a window to treat her and give her the vital antibiotics she needed until the following morning…it was too late. Having heard the evidence – very difficult and very emotive evidence – I know how difficult it was for (UHL) staff who were deeply upset and emotional. It has affected some staff who have resigned or left the UHLG. You (Johnston family) have been living a nightmare since Aoife’s death and this week has been revisiting everything.
“This inquest might end the involvement of a lot of us in Aoife’s case but I know you will be living with this for the rest of your lives. There are no words that can convey the scale of the tragedy you sustained. You bore witness (in UHL) as to everything that happened.”
The inquest issued recommendations including that all Hamilton Report measures on UHL’s emergency department be adopted, all sepsis patients should have their chart specially noted for the infection, there should be a formal plan to deal with overcrowding and all emergency department escalation contacts be made by email and telephone with all to be properly followed up.
Solicitor for the Johnston family, Damien Tansey SC, said they had shown “great dignity and courage” in enduring every parent’s worst nightmare.
He said Aoife had received treatment one would not expect in a third world country. “They find the circumstances of what happened (in UHL) to be incomprehensible. It was an intolerable situation for both doctors and nurses – but it was a dangerous, dangerous situation for this dangerously ill girl,” Mr Tansey said.
“They (James and Carol) were roaring for help for Aoife. They were pleading for help. Aoife was screaming in pain. One doctor (Dr Leandri Card) was moved and took Aoife out of turn. She acted extremely competently in dealing with Aoife and treated her as if she had meningitis.”
An independent inquiry remains ongoing into the circumstances of Aoife’s death as she went over 12 hours unseen by a doctor in the emergency department despite having a letter from a ShannonDoc GP saying that she potentially had sepsis.
The inquest was told by emergency consultant Dr James Gray – who declined to attend UHL on the evening of December 17, 2022 despite a request from a nurse manager concerned about a spiralling overcrowding crisis – that overcrowding had left the emergency department resembling “a death trap” that weekend.
Dr Gray said that he was asked to attend the emergency department on the night of December 17, the night Johnston’s parents brought her to the hospital after being referred by a GP, due to the immense pressure on staff. He said that he was not made aware of any specific cases and that he worked in the hospital’s clinical decision unit throughout the day on Sunday, December 18. He told the court that the system “failed” Johnston.
“Had I known there was a 16-year-old child in septic shock, a Category 2 patient, who couldn’t get into the resus room, the system failed her, the ED failed her, but if I had known there was a patient like that in the department, I would have come in,” Dr. Gray told the inquest. “The problem is I wasn’t asked about a specific case”. Dr. Gray said the ED at UHL is “consistently the worst in the country” and that Johnston received care without dignity or privacy. “It’s an abuse of human rights,” Dr. Gray told the inquest.
Mr and Ms Johnston told the inquest they had to watch their daughter dying despite their pleas for her to be helped.
Aoife had been placed in what they described as a storeroom in the emergency department – and as there were no trolleys available they created a make-shift bed for her from two chairs.
Mr Johnston said he repeatedly begged staff on duty to help his daughter as her skin developed a blotchy-type rash and another mark developed near her eye.
She was getting violently sick and her vomit was green in colour.
“I was up and down to the nurses all night pleading with them to help my daughter,” James said.
“Aoife was screaming in agony with pain to her right leg and head. I heard people outside on the trolleys asking the nurses and doctors to help Aoife. At one point a man said: ‘Is someone not going to go into that girl?’. I continually begged for help.”
Ms Johnston said that at one point they were told Aoife would be treated as if she had meningitis. But they were then asked to help medical staff by holding her down for an intravenous treatment as Aoife’s limbs were by now involuntarily jerking.
Ms Johnston said some staff at UHL were “very mean” to Aoife because she could not stand up by herself for a test.
“At 6am my daughter was finally reviewed by a doctor. She was in agony with pain in her head, her right leg, she was vomiting and she had blotchiness on her skin,” she said.
“The doctor told us that she would treat Aoife as if she had meningitis. After the doctor left, Aoife started to deteriorate even more. James went to the nurses station for help.
“Aoife was taken to resuscitation. By this point, Aoife’s limbs were moving involuntarily. I was asked to hold down my daughter’s arms so they could administer treatment.
“We were subsequently advised that Aoife would be put into an induced coma as there was swelling on her brain and that the coma would allow her body to relax.
“Aoife was moved to ICU. Following a number of scans we were advised that there was nothing that could be done to save Aoife.”
The inquest heard that consultants will attend the UHL emergency department for major emergency cases but not for patient volume matters.
Just one senior house officer, Dr Leandri Card, was left dealing with over 160 patients on December 17/18 as a flood of patients attended the emergency department. But the two senior registrars, Dr Mohamed Hassan and Dr Muneeb Shahid, spent most of their time in the resuscitation room dealing with just over 14 patients, most having suffered fractures due to a cold snap.
Dr Card said medical staff faced “an impossible situation” that weekend.
