THE parents of Aoife Johnston who died in a “death trap” emergency department (ED) at University Hospital Limerick, following “systemic failures” in her care said their daughter died a “horrible death”.
Carol and James Johnston said they wanted their daughter not to be remembered “as the girl who died on a hospital trolley”, but as “a happy, easy-going, happy-go-lucky girl who went to school and did summer jobs”.
“Our lovely 16-year-old girl and our baby was loved very, very much by us and her sisters,” they said.
Following four days of harrowing evidence at Aoife’s inquest, Limerick Coroner John McNamara returned a verdict of medical misadventure in her death from meningitis after she contracted sepsis.
It was, Mr McNamara agreed, “the only verdict” open to him after it had been proposed by Damien Tansey, senior counsel and solicitor for the Johnston family, and not opposed by barristers representing the HSE, UL Hospitals Group, and management at the hospital.
“There were systemic failures and missed opportunities in Aoife’s care,” the coroner said.
“There were breakdowns in communication, clearly, throughout her care.”
The coroner said he was personally “concerned about the overcrowding as a native of Limerick” but he accepted changes were being made.
Aoife was brought to UHL by her parents on Saturday December 17, 2022, after a GP told them he suspected she was deteriorating with sepsis.
The inquest heard hospitals are required to treat sepsis patients within 10-15 minutes. However, UHL did not triage Aoife for over an hour.
Despite being categorised as a sepsis patient, Aoife was 12 more hours waiting for a doctor to examine her.
Facing vomiting green liquid, suffering excruciating pain in her leg, and being light-headed and weak, Aoife waited more than 15 hours in total to receive antibiotics, which it was heard, would likely have saved her.
She was put in what her parents described as a store room at the ED as there was nowhere else for her to go due to the stream of patents in the department.
Her father James wept as he told the inquest that he begged staff to help his daughter. Other patients were advocating for Aoife but she was not seen in time.
The antibiotics she needed were readily available, but because UHL was so short-staffed and overcrowded with patients, staff were delayed in giving them to her. Her brain swelled and she never recovered.
When she got the antibiotics , it was “too late” and she was “beyond recovery”, said Mr Tansey.
‘It is still a death trap’
Dr Jim Gray, who was the only ED consultant on call that weekend, but who was not required to be on site, told the inquest that not only was the ED a “death trap” on the night, “it is still a death trap” five years after Aoife’s death.
Dr Gray said he was concerned for patents attending the ED today, and that despite improvements at UHL, “it is still a dangerous place”.
He said there were not enough beds to meet patient demand and there was still only one ED consultant on call and off site at weekends.
He said it was lucky that most of the emergency cases that present at the hospital were during the daytime and not at night when the hospital does not have the same complement of staff.
He said staff had increased since Aoife’s death, and measures aimed at easing overcrowding were being implemented but these were not being done quickly enough.
“Aoife Johnston had no chance,” he told the coroner.
“The system failed her, the ED failed her. Aoife Johnston had no chance,” he later reiterated.
“It was a dysfunctional environment, it was beyond an emergency — it was an abuse of human rights.”
Under cross examination by Mr Tansey, Dr Gray admitted he had declined a request from a nurse manager to come into the ED on the night Aoife presented.
He told the inquest that consultants who are on-call but off-site at weekends, as he was then, would not normally return to the ED for overcrowding “because it is always overcrowded”.
He reiterated that he received one phone call on the night about the unfolding overcrowding crisis but that he was never told about Aoife.
Indicating he was exhausted when he took the call, Dr Gray said: “I was physically unable to come every single time I was called about it being overcrowded, it was always overcrowded.”
“You have good staff working in a very poor environment – there was leadership but unfortunately leadership just couldn’t cope with the situation.”
‘May as well have been giving Aoife Smarties’
There was only one nurse and one doctor in charge of almost 200 patients who were squeezed together along the corridors of the ED’s Zone A.
Dr Gray said he had been at the hospital earlier on the day and left at 3pm, as it happened two hours before Aoife arrived.
He said he was on-call and offering telephone assistance to staff as well as fielding calls “every hour” from three local injury clinics across Limerick, Clare, and north Tipperary.
Mr Tansey said the two most senior doctors who were on site on the night, both registrars, were treating a wave of fracture patients in the Resus room, off the ED, and it too was swamped with patients.
However they allegedly declined to examine Aoife despite a nurse making three attempts to get them to see her.
Both Dr Mohammed Hassan and Dr Muneeb Shadid told the inquest they did not recall being asked to see Aoife.
Nurse Ciara McCarthy who tried to get Aoife help said she was told to continue giving fluids and paracetamol to Aoife, but, as Mr Tansey put it, she “may as well have been giving (Aoife) Smarties for all the good it did”.
Mr Tansey said one registrar had said the fluids were “as important if not more important” than the antibiotics Aoife had desperately required – which Mr Tansey described as “so absurd it should be disregarded”.
Despite acknowledging an increase of non-consultant hospital doctors at UHL from 25 to 47, Dr Gray warned UHL “is still a dangerous place”.
The consultant told the inquest the present ED was “state of the art” when it was opened in 2017, however, in his opinion it was no longer fit for purpose.
Dr Gray said 24-hour EDs had been closed in north Tipperary, Clare, and St John’s Hospital in Limerick in 2009 and reconfigured to UHL, but he said UHL “did not get the bed cohort to deal with reconfiguration”.
He said the Mid West was the only region without a Model 3 hospital, which would include a 24-hour ED service to complement UHL’s Model 4 status and the only 24-hour ED service for a 425,000 population.
He said two 96-bed blocks coming on stream was “a step in the right direction but it’s not enough”.
When asked again about his decision not to come to the ED on the night, he reiterated he was not aware Aoife was there: “Let me be very clear, I was never consulted to give advice to or attend the ED in respect of Ms Johnston.”
Dr Gray said it was now clear there were “gargantuan” levels of overcrowding in the ED on the night.
He said the lack of beds, lack of staff, and surge of patients on the night had placed “danger on top of danger” in the ED.
There were patients on trollies taking up every available space in the ED, blocking doorways, toilets, and corridors.
He described as “exemplary” the efforts of a junior doctor who was trying to manage 191 patients, including Aoife.
Dr Gray said he told the nurse, who asked him to return to the ED, that he had been working at the department earlier that day and he was due back at the hospital the following Sunday morning.
“An extra person, like a consultant, wouldn’t have perhaps made the difference you may think it would have made,” Dr Gray told Mr Tansey.
He said the only occasions he would be compelled to return to the ED were when a “major emergency plan was activated” or if there was a specific emergency case he had to deal with.
The emergency plan was not activated, and he again said he was not told about Aoife.
Dr Gray said the major emergency plan would have seen not just him but other consultants returning to the hospital, and he said non-urgent patients would have been moved out of the ED.
He said if this would have happened, “it would have helped”.
“I wish I had known there was a 16-year-old child who had entered the emergency department in septic shock, she was a Category 2 patient who couldn’t get into Resus (which was overcrowded),” he said.
He said that patients – known as “borders” – who are regarded as no longer requiring ED care, are routinely left in the ED as there is nowhere else to put them.
Dr Gray claimed that a HSE PMIU (performance management integration unit) in 2022 had effectively “stopped” an internal culture at the hospital of staff moving trollies from the ED up onto wards in order to ease pressure in the ED.
He said, in his opinion, the new guidelines were “rubbish” and not working out in reality.
He said staff had “struggled” to “reactivate” the previous culture of moving trollies to wards.
He said these “two forces” operating at the hospital were “outside off my control”.
‘I’m not superman’
Dr Gray acknowledged that an “escalation plan” was introduced after Aoife’s death which had meant that sepsis and other Category 2 patients were being seen within a maximum 30 minutes, but he agreed these patients should be seen within 10 minutes.
Bed capacity issues and drains on the ED due to overcrowding meant the escalation plan was not working at its “optimum”.
It was luck that the majority of emergencies at the hospital have happened during the day time and not night “because we have more of a workforce to deal with them” then, he said.
Dr Gray said the people who had the greatest knowledge into what happened on the night Aoife presented at the hospital were “the people on site, on the ground”, and he was not one of these.
In his opinion, the hospital required “at least 300 beds” on top two of 96-bed blocks coming on stream.
He said that unless more capacity was provided nurses and doctors would have to “continue assessing and seeing patients in corridors”.
He agreed UHL is “consistently” the most overcrowded in the country and that only one ED consultant remains on-call and off-site on weekends.
“I don’t make the rules, it is not good enough. In an ideal world we would have a consultant on site 24/7.”
Dr Gray said it was “unacceptable” that some Category 2 patients on the night had waited up to 19 hours to be examined by a doctor.
“It was a death trap for Aoife Johnston,” he repeated.
He said he was not involved in Aoife’s care, and that he was asked only to return to provide cover for overcrowding: “Let’s be clear, the role of an ED consultant on call is not to come in when it’s overcrowded.”
When Mr Tansey put it to him that that he was the most senior medic on call, and that his “leadership” was required to help the overwhelmed nurses, Dr Gray retorted: “I’m not Superman.”
He said he would have returned to the ED had he been told about Aoife: “I would have gone back in, I wasn’t asked to come in about a specific case.”
‘It kills me that I never got to say goodbye’
Continuing her touching tribute to Aoife outside the court, Carol Johnstone said Aoife was always a good kid.
“I know every parent says it, but she was no hassle to me and her dad, she was a good kid, and, as James would say, she was a cool kid,” Carol Johnson said, welling up.
Her visibly broken husband, fighting back tears, just as he had when giving evidence to the inquest when he told how he begged staff to help his child, told reporters: “Aoife was the coolest kid, she was my best friend, my baby girl.”
They then both smiled and remembered Aoife on happier occasions: “We had good times, Aoife came on holidays with us every year, even though she would say she was not coming with us because she was too cool but she loved every minute of it. Aoife spent a lot of time with us.”
Their message specifically to Taoiseach Simon Harris and Minister for Health Stephen Donnelly was that a government policy decision in 2009 to close three 24-hour emergency departments in the region and funnel them to Limerick should be reversed.
When asked if the EDs in Ennis and Nenagh and St John’s hospitals should be reopened, they replied: “Yes, 100 per cent, definitely.”
“It’s clear as day, they need another emergency department, definitely.
“We can’t make that happen but from our experience definitely, it shouldn’t happen to another child.
“Aoife is gone now, so all of the apologies and anything they put in place now isn’t going to (bring her back), it’s not going to change that.”
Aoife’s sisters Kate and Meagan broke down outside the court, holding framed pictures of their sister.
Kate Johnston said Aoife was “the best person”, her voice choking up.
Meagan Johnston said: “I’ll never ever forget Aoife, she was the most amazing sister ever, and it kills me that I never got to say goodbye.”
“When I got the call, Aoife was already gone. l’ll never forget that drive into the ICU, I never got to say goodbye to my little sister.
“She was gone and I never got to see my sister complete her Leaving Cert, or see her graduate, or move on to the next chapter with her boyfriend, who has been left heartbroken.
“Even when I knew Aoife was in a hospital, I thought she was going to be ok, and then to get a call she was in ICU, I didn’t know what to do because she is my baby sister and we will never get to see her again.”
In a final tribute, Meagan Johnston said: “I’m just so grateful that we had this beautiful girl, she was a beautiful girl inside and out, she was an amazing person and I will cherish my memories of her forever and ever.”
Looking at her sister’s photograph, Meagan said: “I’m so sorry Aoife for what happened to you, but my mum and dad did everything they could.”
‘Great dignity and courage’
The Coroner endorsed recommendations of the Hamilton Report into UHL’s ED.
“Aoife should have been treated in a timely manner. Time was of the essence and there was a window to treat (Aoife) and give her the vital antibiotics she needed until the following morning, but 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.”
Addressing Aoife’s family, Mr McNamara said: “You have been living a nightmare since Aoife’s death and this week has been revisiting everything – and I know 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 as to everything that happened (in UHL).”
The coroner recommend that all sepsis patients should have their patient chart specially noted as such and there should be a formal escalation plan to deal with overcrowding and all emergency department management contacts be made by email and telephone until management were contacted.
Mr Tansey said the Johnston family had shown “great dignity and courage” as the horrific nature of their daughter’s death was retold over the four days of evidence.
Mr Tansey said what happened in UHL on the night was akin to a “third world country” and not in a developed country in 2022.
Mr Tansey said Aoife’s parents “were roaring and pleading for help for Aoife and she was screaming in pain”.
The HSE and UL Hospitals Group apologised for their failings in Aoife’s care through their representative senior counsel Conor Halpin.
HSE chief executive Bernard Gloster afterwards offered his sincere condolences to the Johnston family.
“I am aware that nothing will ever make up for the enormous loss the Johnston family has experienced,” Mr Johnston said. “The Coroner’s recommendations will be fully considered, along with the work of retired Chief Justice Frank Clarke, who is due to conclude his independent investigation in the coming weeks.”
