The inquest into the death of Aoife Johnston, who died after waiting for more than 15 hours to be administered with “vital” antibiotics that likely would have saved her had she received them earlier, has recorded a verdict of medical misadventure.
In recording his verdict, John McNamara, presiding coroner at Limerick Coroner’s Court, said that Ms Johnston (16) should have been treated in a timely manner “given the illness which she came in with, which was treatable”.
Ms Johnston, late of Shannon, Co Clare, died at University Hospital Limerick (UHL) on December 19th, 2022, from purulent meningitis. She had presented at the hospital’s emergency department two days earlier, at about 5pm on December 17th, suffering from a suspected case of sepsis.
Despite being triaged as a high-priority patient in need of care within 10 to 15 minutes, Ms Johnston waited for hours in the hospital’s “gargantuanly overcrowded” emergency department, and did not receive antibiotics until after 7am on December 18th.
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“There were systemic failures, there were missed opportunities, there were communication breakdowns, clearly,” Mr McNamara said.
He said it was not acceptable that even still, 15 months after Ms Johnston’s death, serious problems with overcrowding persist at the hospital’s emergency department. He made a number of recommendations along with his verdict, and expressed his condolences to the Johnston family.
Speaking outside of Kilmallock Courthouse, Carol and James Johnston, Ms Johnston’s parents, said that their daughter suffered “a horrible death”.
“We arrived on the 17th, and we never thought on the 19th we’d be leaving without Aoife,” Carol Johnston said, surrounded by extended family and friends. “She suffered... I think, you know, people need to know that.
“We told her she was in the best place. ‘Get some rest. The doctors will be here soon.’ And the doctors never came.”
The family said the Government needed to deliver on promises to improve conditions at UHL, and reopen emergency department at other hospitals in the midwest region, in Nenagh and Ennis.
“[I] just hope it’s not all talk. They need to get on with it, and sort it out. More people are going to die in that hospital. One million per cent. They need to sort it out,” Mr Johnston said.
Carol Johnston said that, even now, she’d be “terrified” to attend at UHL, “or if my other children had to go in... and that’s really a sad state of affairs”.
Ms Johnston’s parents said that, at present, their daughter is known as “a girl who died on a trolley”, but in time, they hoped that people would get to know “the real Aoife, the lovely 16-year-old, our baby girl”.
“She was a happy, easygoing girl. Happy-go-lucky, and got up and went to school. Got her summer jobs, done everything,” Carol Johnston said. She often went on holiday with her parents, they said, and spent a lot of time with them.
Ms Johnston’s older sister Meagan became emotional as she spoke of the late teenager: “I’ll never, ever forget Aoife, she was just the most amazing sister ever. It kills me all the time. I never got to say goodbye to her,” she said, tearfully.
Prior to Mr McNamara’s verdict, Damien Tansey SC, solicitor for the Johnston family, urged the coroner to return a verdict of medical misadventure. Conor Halpin SC, for the Health Service Executive (HSE) and UL Hospitals group, and Ciara Daly BL, for UHL’s former general nursing manager Fiona Steed, did not contest Mr Tansey’s submission regarding a verdict.
Limerick Coroner’s Court heard on Wednesday it was “highly likely” that Ms Johnston would have survived had she been treated with antibiotics in a timely and appropriate manner.
Dr Patrick Stapleton, a consultant microbiologist at UHL, told the court on Wednesday that the pathogen present in Ms Johnston’s body, meningococcus, would have responded to antibiotics, and could have been dealt with through a range of such treatments.
Ms Johnston eventually died on December 19th at UHL. The formal cause of death, given by pathologist Dr Terezia Lazlo, was purulent meningitis.
Summarising the evidence put before the inquest on Thursday, Mr Tansey recalled how medical witnesses described the chaotic and war zone-like environment at UHL’s emergency department on the weekend that Ms Johnston presented, having been referred there by a GP who suspected she had sepsis.
“It was an intolerable situation, for both the nurses and the doctors,” he said. “It was a dangerous, dangerous environment, for this dangerously ill patient to find herself in.”
Mr Tansey said the manner in which Ms Johnston was treated was “not suitable” for “one of the citizens of this country... in one of our [medical] centres of excellence”.
He said the Johnston family were on a mission “to vindicate and underpin” Ms Johnston’s life and standing as a person. “She will always be a member of this family,” he said, gesturing to the Johnston family sitting behind him in the courtroom.
Mr Tansey said it was the Johnstons’ “fervent wish... that there will never be a day like this for other families”, and that they hoped some good would come from “an unspeakable tragedy”.
Dr James Gray, the emergency medicine consultant on call that weekend, told the inquest on Thursday the department was “like a death trap” due to the overcrowding.
“Aoife Johnston had no chance,” he told the inquest on Thursday.
Dr Gray, who agreed that he was the most senior clinician working in the hospital’s emergency department while “on-site”, had declined a request to attend the hospital on the night of Ms Johnston’s admission. He noted that it was impossible to attend the hospital due to capacity difficulties at the emergency department, “because it was always overcrowded”.
“I was physically unable to come in,” he said. “I’m not Superman.”
He said he would have attended the emergency department on the evening that Ms Johnston presented at the hospital, December 17th, 2022, had he known about her case.
He noted that when she did receive care from Dr Leandri Card, the senior house officer on duty over the weekend, “she got good care, but it was far too late”.
He said “the only thing that would have worked” in tackling the crisis unfolding at the hospital was enacting the hospital’s “major emergency” plan, but this did not happen.
Activating the plan would have triggered a “cascade” effect, with consultants on call required to attend the hospital.
Despite the implementation of recommendations from the Hamilton report – an independent report carried out following Ms Johnston’s death – the hospital’s emergency department is still a “very dysfunctional environment” today, Dr Gray said. “It’s still a dangerous place, unfortunately.”
Mr Tansey on Thursday described as “absurd” the evidence of Dr Muneeb Shahid, who had suggested to the court on Wednesday that Ms Johnston was retriaged and moved down the patient list in terms of priority on the night in question. Mr Halpin, for the HSE, said it was the hospital’s position that Ms Johnston always remained a Category 2 patient – meaning she should have been seen by a doctor within 10 to 15 minutes of being triaged.
Dr Shahid – one of two registrars who was responsible for the emergency department on the night in question – also said he did not recall nursing staff urging doctors in the resuscitation room to engage with patients elsewhere in the department, including Ms Johnston.
The inquest heard that Dr Shahid, along with registrar Dr Mohamed Hassan, spent extended periods of the night in the resuscitation room, where up to 14 patients were being treated – including patients with bone fractures.
Meanwhile, Minister for Health Stephen Donnelly
offered his “sincere condolences” to Ms Johnston’s family in a statement.
“I would like to thank the coroner for all his work this week, but I am aware that nothing will ever make up for the enormous loss the Johnston family has experienced,” Mr Donnelly 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.”
The coroner made a number of recommendations, including endorsing the recommendations of the Hamilton report, and a review of the current escalation process in identifying a “major emergency” at the hospital out of hours, to ensure there is no delay in making contact with the executive management team.
In a statement, HSE chief executive Bernard Gloster acknowledged the coroner’s verdict and issued an “unequivocal apology”.
“I will now take the outcome of the inquest, study the details of the transcripts and, together with the systems analysis report I received in December, add this to the information available [and] when I receive the outcome of the independent review being conducted by retired Chief Justice Mr Frank Clarke I will consider next steps,” Mr Gloster said.
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